Provider Demographics
NPI:1265624167
Name:RUTLEDGE, MICHAEL R (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:RUTLEDGE
Suffix:
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 1:221 MAHALANI ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2526
Mailing Address - Country:US
Mailing Address - Phone:808-244-9056
Mailing Address - Fax:770-474-8510
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-244-9056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC166106207RC0000X
GA072449207RC0000X
TXN2272207RC0000X
ND17861207RC0000X
WI76742-20207RC0000X
HIMD-21985207RC0000X
FLME154886207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003148512AMedicaid
GA003148512AMedicaid