MEDICARE: EDWARD J PUTTRE JR MD INC

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	207W00000X	Ophthalmology Physician	G22264	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336281443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD J PUTTRE JR MD INC

Provider Business Mailing Address
First Line	:	1800 WESTERN AVE
Second Line	:	SUITE 101
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92411-1356
Country	:	US
Telephone Number	:	909-887-3937
Fax Number	:	909-887-9698

Provider Business Practice Location Address
First Line	:	1800 WESTERN AVE
Second Line	:	SUITE 101
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92411-1356
Country	:	US
Telephone Number	:	909-887-3937
Fax Number	:	909-887-9698

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EDWARD J PUTTRE JR.
Credential	:	MD
Telephone Number	:	909-887-3937

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	08/23/2010

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