Provider Demographics
NPI:1396931689
Name:RUTTANASEE, JET THANETR (OD)
Entity type:Individual
Prefix:
First Name:JET
Middle Name:THANETR
Last Name:RUTTANASEE
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 1:11035 72ND RD
Mailing Address - Street 2:APT. 605
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5471
Mailing Address - Country:US
Mailing Address - Phone:347-901-0183
Mailing Address - Fax:
Practice Address - Street 1:7010 AUSTIN ST STE 2
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4763
Practice Address - Country:US
Practice Address - Phone:718-575-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV 007165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03086528Medicaid
NY03086528Medicaid