Provider Demographics
NPI:1609850908
Name:SUTTOR, RANDALL JON (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JON
Last Name:SUTTOR
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550-9310
Practice Address - Country:US
Practice Address - Phone:574-862-2165
Practice Address - Fax:574-862-4112
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032363A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173790Medicaid
IN162520ZOtherMEDICARE PTAN
IN178420004OtherMEDICARE PTAN
INM400034991OtherMEDICARE PTAN
INE15738Medicare UPIN
IN162520ZMedicare PIN