Healthcare Provider Details

I. General information

NPI: 1063626711
Provider Name (Legal Business Name): SYNA M. KUTTOTHARA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BALDWIN PARK BLVD FAMILY MEDICINE DEPARTMENT
BALDWIN PARK CA
91706-5806
US

IV. Provider business mailing address

1011 BALDWIN PARK BLVD FAMILY MEDICINE DEPARTMENT
BALDWIN PARK CA
91706-5806
US

V. Phone/Fax

Practice location:
  • Phone: 800-780-1277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54791
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301085828
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA117903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: