Provider Demographics
NPI:1558334672
Name:KALUTZ, THEODORE EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:EUGENE
Last Name:KALUTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 HAILE STREET
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020
Mailing Address - Country:US
Mailing Address - Phone:803-432-1931
Mailing Address - Fax:803-432-1176
Practice Address - Street 1:1346 HAILE STREET
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020
Practice Address - Country:US
Practice Address - Phone:803-432-1931
Practice Address - Fax:803-432-1176
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8535208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC085357Medicaid