Healthcare Provider Details

I. General information

NPI: 1174738587
Provider Name (Legal Business Name): JOHN JOSEPH HUTNICK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MAIN STREET
BENTON PA
17814-0275
US

IV. Provider business mailing address

PO BOX 275
BENTON PA
17814-0275
US

V. Phone/Fax

Practice location:
  • Phone: 570-925-6111
  • Fax:
Mailing address:
  • Phone: 570-925-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0E005651P
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002454
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: