Provider Demographics
NPI:1295991065
Name:MOUTREY, TODD L (BA, SFA, SA-C)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:L
Last Name:MOUTREY
Suffix:
Gender:M
Credentials:BA, SFA, SA-C
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 31630
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1630
Mailing Address - Country:US
Mailing Address - Phone:520-784-6200
Mailing Address - Fax:520-784-6109
Practice Address - Street 1:2424 N. WYATT DR.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6118
Practice Address - Country:US
Practice Address - Phone:520-784-6200
Practice Address - Fax:520-784-6109
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99-197246ZC0007X
AZ99-197246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist