Provider Demographics
NPI:1700989118
Name:DUTRA, DAVID LEE (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:DUTRA
Suffix:
Gender:M
Credentials:DPM
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 938
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-0938
Mailing Address - Country:US
Mailing Address - Phone:209-223-3030
Mailing Address - Fax:209-223-5864
Practice Address - Street 1:613 NEW YORK RANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9328
Practice Address - Country:US
Practice Address - Phone:209-223-3030
Practice Address - Fax:209-223-5864
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3190213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T11572Medicare UPIN
CA0781440001Medicare NSC