MEDICARE: DR. STEVEN RAY RUTAN O.D.

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	152W00000X	Optometrist	18001701A	IN

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	:	1588630149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEVEN RAY RUTAN O.D.

Provider Business Mailing Address
First Line	:	5229 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-5538
Country	:	US
Telephone Number	:	260-484-1453
Fax Number	:	260-483-8287

Provider Business Practice Location Address
First Line	:	5229 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-5538
Country	:	US
Telephone Number	:	260-484-1453
Fax Number	:	260-483-8287

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

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	07/06/2010

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