Provider Demographics
NPI:1770620908
Name:KUTNICK, RICHARD T (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:KUTNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31-00 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3963
Mailing Address - Country:US
Mailing Address - Phone:201-693-4445
Mailing Address - Fax:201-762-6109
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:201-693-4445
Practice Address - Fax:201-762-6109
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10723700207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC09093Medicare UPIN
NY356661Medicare PIN