Healthcare Provider Details

I. General information

NPI: 1700989118
Provider Name (Legal Business Name): DAVID LEE DUTRA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 11/23/2011
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:
Title or Position:
Credential:
Phone: