MEDICARE: TIMOTHY GEORGE DUTRA DPM

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	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	E33830	CA

General Provider Information

NPI Number	:	1588650162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY GEORGE DUTRA DPM

Provider Business Mailing Address
First Line	:	13847 E 14TH ST
Second Line	:	#110A
City	:	SAN LEANDRO
State	:	CA
Zip	:	94578-2632
Country	:	US
Telephone Number	:	510-351-7122
Fax Number	:	510-351-1797

Provider Business Practice Location Address
First Line	:	13847 E 14TH ST
Second Line	:	#110A
City	:	SAN LEANDRO
State	:	CA
Zip	:	94578-2632
Country	:	US
Telephone Number	:	510-351-7122
Fax Number	:	510-351-1797

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	07/08/2007

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