Provider Demographics
NPI:1932170859
Name:SUTPHEN, ERIC (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SUTPHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 DUNN RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-7928
Mailing Address - Country:US
Mailing Address - Phone:314-315-9913
Mailing Address - Fax:314-872-8069
Practice Address - Street 1:450 N NEW BALLAS RD STE 70W
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6833
Practice Address - Country:US
Practice Address - Phone:314-227-2301
Practice Address - Fax:314-227-2316
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2P242085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203032628Medicaid
MOP00146606OtherRAILROAD MEDICARE
MOP00146606OtherRAILROAD MEDICARE
MO203032628Medicaid
MOE85350Medicare UPIN