Healthcare Provider Details

I. General information

NPI: 1285748996
Provider Name (Legal Business Name): JORGE LUIS KUTUGATA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 S AIRPORT DR STE 1
WESLACO TX
78596-6649
US

IV. Provider business mailing address

902 S AIRPORT DR STE 1
WESLACO TX
78596-6649
US

V. Phone/Fax

Practice location:
  • Phone: 956-969-2904
  • Fax: 956-969-1650
Mailing address:
  • Phone: 956-969-2904
  • Fax: 956-969-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG9139
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG9139
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: