Provider Demographics
NPI:1497861033
Name:KUTLERYWALA, KETAN HARSHADRAY (OD)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:HARSHADRAY
Last Name:KUTLERYWALA
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 1:310 WINDSOR HWY
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-6908
Mailing Address - Country:US
Mailing Address - Phone:845-541-9689
Mailing Address - Fax:
Practice Address - Street 1:63 W PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1334
Practice Address - Country:US
Practice Address - Phone:201-845-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00699500152W00000X
TX6818T152W00000X
NY7391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist