Basic Information
| Provider Information | |||||||||
| NPI: | 1255359105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUTAI | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9398-1 ARLINGTON EXPY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322258213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047249210 | ||||||||
| FaxNumber: | 9047243680 | ||||||||
| Practice Location | |||||||||
| Address1: | 9398-1 ARLINGTON EXPY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322258213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047249210 | ||||||||
| FaxNumber: | 9047243680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC4402 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 009937627 | 05 | AL | MEDICAID |