Provider Demographics
NPI:1871693838
Name:SUTPHIN, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:SUTPHIN
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 1:1180 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901
Mailing Address - Country:US
Mailing Address - Phone:307-362-4200
Mailing Address - Fax:307-362-5406
Practice Address - Street 1:1180 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901
Practice Address - Country:US
Practice Address - Phone:307-362-4200
Practice Address - Fax:307-362-5406
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3547A208800000X
UT166834-1205208800000X
CAG42452208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104849000Medicaid
WY2266OtherBCBS-WY
WY340001047OtherUPREHA
WY1312335OtherUMWA
WY4108766Medicare ID - Type Unspecified
WYA73026Medicare UPIN