Provider Demographics
NPI:1407186893
Name:CHARLES L CUTLER, M.D., P.A.
Entity Type:Organization
Organization Name:CHARLES L CUTLER, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:CUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-734-0337
Mailing Address - Street 1:630 ADDISON AVE W STE 220
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5474
Mailing Address - Country:US
Mailing Address - Phone:208-734-0337
Mailing Address - Fax:208-733-3561
Practice Address - Street 1:630 ADDISON AVE W STE 220
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5474
Practice Address - Country:US
Practice Address - Phone:208-734-0337
Practice Address - Fax:208-733-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3817174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002485700Medicaid
ID38174OtherBLUE CROSS
ID11122504Medicare PIN