Provider Demographics
NPI:1952304289
Name:RUTZ, VIRGINIA (DO)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:RUTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:AZ
Mailing Address - Zip Code:85237-0369
Mailing Address - Country:US
Mailing Address - Phone:520-363-5573
Mailing Address - Fax:520-363-5611
Practice Address - Street 1:100 TILBURY DR.
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:AZ
Practice Address - Zip Code:85237
Practice Address - Country:US
Practice Address - Phone:520-363-5573
Practice Address - Fax:520-363-5611
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ359168Medicaid
AZ61071Medicare ID - Type UnspecifiedMEDICARE
G29582Medicare UPIN
AZ359168Medicaid
AZZ79112Medicare PIN