Healthcare Provider Details

I. General information

NPI: 1528449220
Provider Name (Legal Business Name): ISSA H KUTKUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BROADWAY STE 200
FORT WAYNE IN
46802-2149
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY SUITE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-3410
  • Fax: 260-425-2881
Mailing address:
  • Phone: 260-479-3514
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01087821A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: