MEDICARE: DENNIS J KAUTZMAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901002310	MI

General Provider Information

NPI Number	:	1023171857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS J KAUTZMAN O.D.

Provider Business Mailing Address
First Line	:	3121 E VILLAGE LN
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-1404
Country	:	US
Telephone Number	:	810-385-8152
Fax Number	:	810-385-9638

Provider Business Practice Location Address
First Line	:	4460 24TH AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3809
Country	:	US
Telephone Number	:	810-385-9638
Fax Number	:	810-385-8105

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	07/08/2007

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