Provider Demographics
NPI:1124539465
Name:DUTTERA, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:DUTTERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 SOFIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17361
Mailing Address - Country:US
Mailing Address - Phone:717-942-2049
Mailing Address - Fax:
Practice Address - Street 1:96 SOFIA DR
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:PA
Practice Address - Zip Code:17361-5201
Practice Address - Country:US
Practice Address - Phone:717-942-2049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAFO3701237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAFO3701OtherPA HIS LICENSE