Provider Demographics
NPI:1700888120
Name:DUTKO, LES (EDD, LAT, ATC)
Entity Type:Individual
Prefix:DR
First Name:LES
Middle Name:
Last Name:DUTKO
Suffix:
Gender:M
Credentials:EDD, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 NOAHS CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-5459
Mailing Address - Country:US
Mailing Address - Phone:304-263-1479
Mailing Address - Fax:301-797-7066
Practice Address - Street 1:222 E OAK RIDGE DR
Practice Address - Street 2:SUITE 1800
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7858
Practice Address - Country:US
Practice Address - Phone:301-739-0090
Practice Address - Fax:301-739-0288
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260006032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0126000603OtherLICSENED ATHLETIC TRAINER