Healthcare Provider Details

I. General information

NPI: 1811088388
Provider Name (Legal Business Name): THEODORE JOHN KUTCHER II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 FRIENDSHIP ST DEPARTMENT OF DIAGNOSTIC IMAGING
NEWPORT RI
02840-2209
US

IV. Provider business mailing address

24 CEDAR ST
NARRAGANSETT RI
02882-3930
US

V. Phone/Fax

Practice location:
  • Phone: 401-845-4253
  • Fax: 401-848-6008
Mailing address:
  • Phone: 401-782-1254
  • Fax: 401-782-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number08823
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: