MEDICARE: SUTERA NUDTAVUTHTISIT DOCTOR OF OPTOMETRY

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	15263 TLG	CA

General Provider Information

NPI Number	:	1770969701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUTERA NUDTAVUTHTISIT DOCTOR OF OPTOMETRY

Provider Business Mailing Address
First Line	:	2629 E BROOKSIDE AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92867-4008
Country	:	US
Telephone Number	:	949-463-6817
Fax Number	:

Provider Business Practice Location Address
First Line	:	1319 S HARBOR BLVD
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92832-3001
Country	:	US
Telephone Number	:	714-525-3330
Fax Number	:	714-525-3334

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

Provider Enumeration Date	:	07/31/2015
Last Update Date	:	11/15/2016

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