Provider Demographics
NPI:1568499242
Name:RUTRICK, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:RUTRICK
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 1:56 SOMERSET RD
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2722
Mailing Address - Country:US
Mailing Address - Phone:617-775-1818
Mailing Address - Fax:617-744-8543
Practice Address - Street 1:521 MOUNT AUBURN ST STE 107-109
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4191
Practice Address - Country:US
Practice Address - Phone:617-775-1818
Practice Address - Fax:617-744-8543
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36462174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA33612Medicare UPIN