Healthcare Provider Details

I. General information

NPI: 1003827668
Provider Name (Legal Business Name): TIMOTHY J KUTZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-6406
  • Fax: 314-268-2712
Mailing address:
  • Phone: 314-268-6406
  • Fax: 314-268-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2001016564
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number2001016564
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: