Healthcare Provider Details

I. General information

NPI: 1205375052
Provider Name (Legal Business Name): JEFFRY KUTHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MARINA LAKES DR
RICHMOND CA
94804-7448
US

IV. Provider business mailing address

40 MARINA LAKES DR
RICHMOND CA
94804-7448
US

V. Phone/Fax

Practice location:
  • Phone: 216-870-7615
  • Fax:
Mailing address:
  • Phone: 216-870-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number808932
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: