Healthcare Provider Details

I. General information

NPI: 1164534178
Provider Name (Legal Business Name): PAUL WILLIAM WUTHRICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 SAGEBRIAR DR
BRYAN TX
77802-6107
US

IV. Provider business mailing address

20850 FM 159 RD
NAVASOTA TX
77868-7014
US

V. Phone/Fax

Practice location:
  • Phone: 979-774-0498
  • Fax:
Mailing address:
  • Phone: 936-825-7535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberH8528
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: