=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710987805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRETT CUTLER DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 06/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 SOUTHPARK BLVD STE A103
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-4162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-0869
-----------------------------------------------------
Fax | 904-826-0966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 SOUTHPARK BLVD STE A103
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-4162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-0869
-----------------------------------------------------
Fax | 904-826-0966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | P02940
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------