Provider Demographics
NPI:1588632327
Name:BRUTICO, CARMEN A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:A
Last Name:BRUTICO
Suffix:JR
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 1:743 JEFFERSON AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1639
Mailing Address - Country:US
Mailing Address - Phone:570-344-9457
Mailing Address - Fax:570-343-3731
Practice Address - Street 1:743 JEFFERSON AVE STE 302
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1639
Practice Address - Country:US
Practice Address - Phone:570-344-9457
Practice Address - Fax:570-343-3731
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025153E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000908699Medicaid
PA000908699Medicaid
PA156554Medicare PIN