Healthcare Provider Details

I. General information

NPI: 1336303114
Provider Name (Legal Business Name): CORY ALLEN KUTLICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 E MAIN ST BOX 328
KENT OH
44240-5818
US

IV. Provider business mailing address

1675 E MAIN ST BOX 328
KENT OH
44240-5818
US

V. Phone/Fax

Practice location:
  • Phone: 330-593-1049
  • Fax: 330-572-3836
Mailing address:
  • Phone: 330-593-1049
  • Fax: 330-572-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34.010220
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: