Provider Demographics
NPI:1326007022
Name:KUTYLA, MARK RAYMOND (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYMOND
Last Name:KUTYLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:R
Other - Last Name:KUTYLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 PARK PLACE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-6690
Practice Address - Country:US
Practice Address - Phone:803-356-4712
Practice Address - Fax:803-356-0832
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC516213EP1101X, 213ER0200X, 213ES0000X, 2471M1202X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1020003OtherACM - MIDLANDS FOOT CLINIC
SC1326007022OtherNPI # MARK R KUTYLA DPM
SC7238051OtherAETNA PROVIDER
SC1720032816OtherNPI # FOR MIDLANDS FOOT CLINIC - PRIMARY PRACTICE LOCATION
SC42D2921723OtherCLIA CERTIFICATE OF WAIVER FOR NEWBERRY FOOT CLINIC LOCATION
SC1851338461OtherNPI # FOR NEWBERRY FOOT CLINIC - ADDITIONAL PRACTICE LOCATION
SCK066682OtherINTEGRATED HEALTH PLAN PROVIDER
SC0433675OtherCIGNA PROVIDER
SC480032059OtherMEDICARE RAILROAD PROVIDER
SC1015587OtherACM - NEWBERRY FOOT CLINIC
SC42D2021725OtherCLIA CERTIFICATE OF WAIVER FOR MIDLANDS FOOT CLINIC LOCATION
SC1720032816OtherNPI # FOR MIDLANDS FOOT CLINIC - PRIMARY PRACTICE LOCATION
SC4207850001Medicare NSC
SC0433675OtherCIGNA PROVIDER
SC1326007022OtherNPI # MARK R KUTYLA DPM
SC4207850002Medicare NSC