Healthcare Provider Details

I. General information

NPI: 1720032816
Provider Name (Legal Business Name): MARK R KUTYLA DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 11/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PARK PLACE CT
LEXINGTON SC
29072-6690
US

IV. Provider business mailing address

121 PARK PLACE CT
LEXINGTON SC
29072-6690
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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 Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number516
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number516
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number516
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number516
License Number StateSC
# 8
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number516
License Number StateSC

VIII. Authorized Official

Name: DR. MARK R KUTYLA
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 803-356-4712