Provider Demographics
NPI:1245206408
Name:KUTSY, ROMAN L (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:L
Last Name:KUTSY
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 1:2326 RUCKER AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2723
Mailing Address - Country:US
Mailing Address - Phone:425-259-5121
Mailing Address - Fax:425-252-9068
Practice Address - Street 1:2326 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2723
Practice Address - Country:US
Practice Address - Phone:425-259-5121
Practice Address - Fax:425-252-9068
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032822204D00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1118462Medicaid
WA1118462Medicaid
G10879Medicare UPIN