1770969701 NPI number — SUTERA NUDTAVUTHTISIT DOCTOR OF OPTOMETRY

Table of content: SUTERA NUDTAVUTHTISIT DOCTOR OF OPTOMETRY (NPI 1770969701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770969701 NPI number — SUTERA NUDTAVUTHTISIT DOCTOR OF OPTOMETRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUDTAVUTHTISIT
Provider First Name:
SUTERA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DOCTOR OF OPTOMETRY
Provider Gender Code:
F

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:
1770969701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2629 E BROOKSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92867-4008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-463-6817
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1319 S HARBOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92832-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-525-3330
Provider Business Practice Location Address Fax Number:
714-525-3334
Provider Enumeration Date:
07/31/2015

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:  15263 TLG , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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