Provider Demographics
NPI:1487612107
Name:SUNDERLAND, THERESA KAY (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:KAY
Last Name:SUNDERLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-7508
Practice Address - Fax:704-384-8666
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300291208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0029BMedicaid
NC891369FMedicaid
H53208Medicare UPIN