Provider Demographics
NPI:1336281443
Name:EDWARD J PUTTRE JR MD INC
Entity Type:Organization
Organization Name:EDWARD J PUTTRE JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:PUTTRE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-887-3937
Mailing Address - Street 1:1800 WESTERN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1356
Mailing Address - Country:US
Mailing Address - Phone:909-887-3937
Mailing Address - Fax:909-887-9698
Practice Address - Street 1:1800 WESTERN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1356
Practice Address - Country:US
Practice Address - Phone:909-887-3937
Practice Address - Fax:909-887-9698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22264207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G222640Medicaid
CA00G222640Medicare ID - Type Unspecified
CAA41527Medicare UPIN