MEDICARE: RANDY W DUTTON OPTOMETRIST

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	1827	MN

General Provider Information

NPI Number	:	1902891468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDY W DUTTON OPTOMETRIST

Provider Business Mailing Address
First Line	:	2520 VILLAGE LN
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-8745
Country	:	US
Telephone Number	:	321-269-3405
Fax Number	:

Provider Business Practice Location Address
First Line	:	1381 S PATRICK DR
Second Line	:
City	:	PATRICK AFB
State	:	FL
Zip	:	32925-3606
Country	:	US
Telephone Number	:	321-494-8164
Fax Number	:	321-494-1378

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

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	11/21/2011

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