Healthcare Provider Details

I. General information

NPI: 1619031630
Provider Name (Legal Business Name): KUTCHBACK PODIATRY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9004 FOREST CROSSING DRIVE SUITE C
THE WOODLANDS TX
77381
US

IV. Provider business mailing address

71 N SUMMER CLOUD DR
THE WOODLANDS TX
77381-6224
US

V. Phone/Fax

Practice location:
  • Phone: 281-298-5053
  • Fax: 832-797-6898
Mailing address:
  • Phone: 936-273-7831
  • Fax: 936-273-7831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1755
License Number StateTX

VIII. Authorized Official

Name: JAMES W KUTCHBACK
Title or Position: OWNER
Credential: DPM
Phone: 281-298-5053