Provider Demographics
NPI:1326093303
Name:KUTROSKY, THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:KUTROSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5269 LANKERSHIM BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-3111
Mailing Address - Country:US
Mailing Address - Phone:818-769-2020
Mailing Address - Fax:818-769-2024
Practice Address - Street 1:5269 LANKERSHIM BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-3111
Practice Address - Country:US
Practice Address - Phone:818-769-2020
Practice Address - Fax:818-769-2024
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA04267T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA04267TOtherCA STATE LICENSE
CAT09615Medicare UPIN
CAOP4267Medicare ID - Type Unspecified