MEDICARE: MARK LIVINGSTON JUTRAS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VE0102X	Reproductive Endocrinology Physician	54438	FL
2	207VE0102X	Reproductive Endocrinology Physician	2006-01581	NC

General Provider Information

NPI Number	:	1093771792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LIVINGSTON JUTRAS MD

Provider Business Mailing Address
First Line	:	1918 RANDOLPH RD STE 210
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1109
Country	:	US
Telephone Number	:	704-947-9000
Fax Number	:	704-992-1900

Provider Business Practice Location Address
First Line	:	1918 RANDOLPH RD STE 210
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1109
Country	:	US
Telephone Number	:	704-947-9000
Fax Number	:	704-992-1900

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2006
Last Update Date	:	03/17/2018

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