Healthcare Provider Details

I. General information

NPI: 1326007022
Provider Name (Legal Business Name): MARK RAYMOND KUTYLA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK R KUTYLA DPM

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PARK PLACE CT
LEXINGTON SC
29072-6690
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-356-4712
  • Fax: 803-356-0832
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number516
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number516
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number516
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number516
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number516
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: