Provider Demographics
NPI:1588630149
Name:RUTAN, STEVEN RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:RAY
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 1:5229 COLDWATER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5538
Mailing Address - Country:US
Mailing Address - Phone:260-484-1453
Mailing Address - Fax:260-483-8287
Practice Address - Street 1:5229 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5538
Practice Address - Country:US
Practice Address - Phone:260-484-1453
Practice Address - Fax:260-483-8287
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001701A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100054070AMedicaid
IN100054070AMedicaid
T98128Medicare UPIN