Provider Demographics
NPI:1417947680
Name:RUTKOWSKY, WALTER F (OD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:F
Last Name:RUTKOWSKY
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 1:5005 MANATEE AVENUE WEST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-3857
Mailing Address - Country:US
Mailing Address - Phone:941-794-1315
Mailing Address - Fax:941-792-5034
Practice Address - Street 1:5005 MANATEE AVENUE WEST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3857
Practice Address - Country:US
Practice Address - Phone:941-794-1315
Practice Address - Fax:941-792-5034
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1555152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078099500Medicaid
4545097OtherAETNA
2312704OtherAETNA
580001115OtherRAILROAD MEDICARE
FL19203OtherBCBS OF FLORIDA
580001115OtherRAILROAD MEDICARE
FL078099500Medicaid