Healthcare Provider Details

I. General information

NPI: 1285910737
Provider Name (Legal Business Name): VICTOR KUTOVY MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 E MAIN ST
MENDHAM NJ
07945-1502
US

IV. Provider business mailing address

65 E MAIN ST
MENDHAM NJ
07945-1502
US

V. Phone/Fax

Practice location:
  • Phone: 973-543-2501
  • Fax: 973-543-6150
Mailing address:
  • Phone: 973-543-2501
  • Fax: 973-543-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00097800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: