Provider Demographics
NPI:1043339328
Name:DAVID L DUTRA DPM INC
Entity Type:Organization
Organization Name:DAVID L DUTRA DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:209-223-3030
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-0938
Mailing Address - Country:US
Mailing Address - Phone:209-223-3030
Mailing Address - Fax:209-223-5864
Practice Address - Street 1:613 NEW YORK RANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9328
Practice Address - Country:US
Practice Address - Phone:209-223-3030
Practice Address - Fax:209-223-5864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3190213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0781440001Medicare NSC