Basic Information
| Provider Information | |||||||||
| NPI: | 1194927640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRETT CUTLER DPM PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 105 SOUTHPARK BLVD | ||||||||
| Address2: | SUITE A103 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048240869 | ||||||||
| FaxNumber: | 9048260966 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 SOUTHPARK BLVD | ||||||||
| Address2: | SUITE A103 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048240869 | ||||||||
| FaxNumber: | 9048260966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUTLER | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9048240869 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.P.M. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO 2940 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 21590 | 01 | FL | BLUE SHIELD | OTHER | 340202900 | 05 | FL | MEDICAID | 4298427 | 01 | FL | AETNA | OTHER |