Healthcare Provider Details

I. General information

NPI: 1255203485
Provider Name (Legal Business Name): MARK HUTTER RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 10/24/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 W 38TH ST
INDIANAPOLIS IN
46254-2995
US

IV. Provider business mailing address

436 VENUS DR
INDIANAPOLIS IN
46241-3669
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-3838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37004417A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: