Healthcare Provider Details

I. General information

NPI: 1821187402
Provider Name (Legal Business Name): BRENT L KUTACH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 LONDONDERRY DR SUITE 105
WACO TX
76712-7924
US

IV. Provider business mailing address

PO BOX 224137
DALLAS TX
75222-4137
US

V. Phone/Fax

Practice location:
  • Phone: 254-776-0266
  • Fax: 254-776-2511
Mailing address:
  • Phone: 254-776-0266
  • Fax: 254-776-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberK6070
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: