1285707265 NPI number — LARRY G RUTLEDGE O.D.

Table of content: LARRY G RUTLEDGE O.D. (NPI 1285707265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285707265 NPI number — LARRY G RUTLEDGE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTLEDGE
Provider First Name:
LARRY
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285707265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 ALLEN DR
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45150-8763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-965-2020
Provider Business Mailing Address Fax Number:
513-965-2025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 ALLEN DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45150-8763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-965-2020
Provider Business Practice Location Address Fax Number:
513-965-2025
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3266 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000011879 . This is a "BLUE CROSS & BLUE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 22-00925 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 311157870004 . This is a "MEDICAL MUTUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 311157870 . This is a "VSP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3266 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32843 . This is a "COORDINATED VISION CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: OH3266 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 311157870 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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