Provider Demographics
NPI:1801848585
Name:RUTTUM, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:RUTTUM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC OPHTHALMOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2020
Mailing Address - Fax:414-266-2027
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC OPHTHALMOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2020
Practice Address - Fax:414-266-2027
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI21829207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801848585Medicaid
002000140VOtherHUMANA
WI1801848585Medicaid
WI047873601Medicare PIN
WI028568086Medicare PIN