Healthcare Provider Details

I. General information

NPI: 1992025332
Provider Name (Legal Business Name): DARYL R DUTTER MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N WILMA AVE STE A
RIPON CA
95366-9503
US

IV. Provider business mailing address

PO BOX 210
RIPON CA
95366-0210
US

V. Phone/Fax

Practice location:
  • Phone: 209-599-4211
  • Fax: 209-599-7348
Mailing address:
  • Phone: 209-599-4211
  • Fax: 209-599-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG57233
License Number StateCA

VIII. Authorized Official

Name: DR. DARYL R DUTTER
Title or Position: PRESIDENT
Credential: MD
Phone: 209-599-4211