Provider Demographics
NPI:1295710127
Name:RUTTIG, NATHANIEL JACOB (MD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:JACOB
Last Name:RUTTIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1480 HICKORY ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8846
Mailing Address - Country:US
Mailing Address - Phone:850-760-0500
Mailing Address - Fax:850-760-0501
Practice Address - Street 1:1480 HICKORY ST
Practice Address - Street 2:SUITE 104
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8846
Practice Address - Country:US
Practice Address - Phone:850-760-0500
Practice Address - Fax:850-760-0501
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 116522207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008905700Medicaid
FL187409ZCR9Medicare PIN