Healthcare Provider Details

I. General information

NPI: 1043339328
Provider Name (Legal Business Name): DAVID L DUTRA DPM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 NEW YORK RANCH RD
JACKSON CA
95642-9328
US

IV. Provider business mailing address

PO BOX 938
JACKSON CA
95642-0938
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-3030
  • Fax: 209-223-5864
Mailing address:
  • Phone: 209-223-3030
  • Fax: 209-223-5864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3190
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID L DUTRA
Title or Position: OWNER PRESIDENT
Credential: D.P.M.
Phone: 209-223-3030