Provider Demographics
NPI:1295729994
Name:SRUT, IVAN JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:JOSEPH
Last Name:SRUT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 SOUTHWEST FWY
Mailing Address - Street 2:SUITE 155
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-7169
Mailing Address - Country:US
Mailing Address - Phone:713-961-0940
Mailing Address - Fax:713-961-1996
Practice Address - Street 1:4635 SOUTHWEST FWY
Practice Address - Street 2:SUITE 155
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-7169
Practice Address - Country:US
Practice Address - Phone:713-961-0940
Practice Address - Fax:713-961-1996
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5342TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8D7914Medicare ID - Type Unspecified