Provider Demographics
NPI:1821081613
Name:RUTAN, DOUGLAS BRENT (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BRENT
Last Name:RUTAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 33RD ST STE 206
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2776
Mailing Address - Country:US
Mailing Address - Phone:360-695-1334
Mailing Address - Fax:360-992-1159
Practice Address - Street 1:100 E 33RD ST STE 206
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2776
Practice Address - Country:US
Practice Address - Phone:360-695-1334
Practice Address - Fax:360-992-1159
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP0515213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
164425100000OtherPREMARA
480014538OtherRR MCR
WA2047640Medicaid
050259000OtherBC
164425100000OtherPREMARA
WA1084516Medicaid
164425100000OtherPREMARA
G000615627Medicare PIN
050259000OtherBC