Provider Demographics
NPI:1689141889
Name:RUTLEDGE, KIRI J (OD)
Entity Type:Individual
Prefix:
First Name:KIRI
Middle Name:J
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-4232
Mailing Address - Country:US
Mailing Address - Phone:321-267-2020
Mailing Address - Fax:321-267-4165
Practice Address - Street 1:551 NATIONAL HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1495
Practice Address - Country:US
Practice Address - Phone:386-323-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5636152W00000X
PAOEG003436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist