Provider Demographics
NPI:1487643268
Name:RUTAN, CHARLES HUGH (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HUGH
Last Name:RUTAN
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 1:224 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-2312
Mailing Address - Country:US
Mailing Address - Phone:765-832-3292
Mailing Address - Fax:765-832-9730
Practice Address - Street 1:224 ELM ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2312
Practice Address - Country:US
Practice Address - Phone:765-832-3292
Practice Address - Fax:765-832-9730
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002266A152W00000X, 152WC0802X, 152WP0200X
IN1800226A152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351776119OtherTRICARE
IN000000087765OtherBLUE CROSS BLUE SHIELD
IN100243930COtherMEDICAID LOCATION C
IN100243930Medicaid
IN0451720001Medicare NSC
IN858880Medicare PIN
IN100243930Medicaid