Healthcare Provider Details

I. General information

NPI: 1639439409
Provider Name (Legal Business Name): KUTCHBACK PODIATRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17191 ST LUKES WAY SUITE 290
THE WOODLANDS TX
77384-8042
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 936-273-3311
  • Fax: 936-273-3368
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: MRS. ELIZABETH KUTCHBACK
Title or Position: OFFICE CONTACT
Credential:
Phone: 936-273-7831