Provider Demographics
NPI:1770969701
Name:NUDTAVUTHTISIT, SUTERA (DOCTOR OF OPTOMETRY)
Entity type:Individual
Prefix:
First Name:SUTERA
Middle Name:
Last Name:NUDTAVUTHTISIT
Suffix:
Gender:F
Credentials:DOCTOR OF OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 E BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-4008
Mailing Address - Country:US
Mailing Address - Phone:949-463-6817
Mailing Address - Fax:
Practice Address - Street 1:1319 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-3001
Practice Address - Country:US
Practice Address - Phone:714-525-3330
Practice Address - Fax:714-525-3334
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15263 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist