Healthcare Provider Details

I. General information

NPI: 1770159493
Provider Name (Legal Business Name): KEITH MCCUTCHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

IV. Provider business mailing address

275 N GARFIELD AVE APT 7A
PASADENA CA
91101-1547
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-5000
  • Fax:
Mailing address:
  • Phone: 970-379-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: