Provider Demographics
NPI:1053307272
Name:RUTLEDGE, BRYAN KYLE (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KYLE
Last Name:RUTLEDGE
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 1:200 GREENFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6655
Mailing Address - Country:US
Mailing Address - Phone:315-445-8166
Mailing Address - Fax:315-445-2697
Practice Address - Street 1:200 GREENFIELD PKWY
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6655
Practice Address - Country:US
Practice Address - Phone:315-445-8166
Practice Address - Fax:315-445-2697
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203254207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01668437Medicaid
F80487Medicare UPIN
NY01668437Medicaid