Provider Demographics
NPI:1285748996
Name:KUTUGATA, JORGE LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:KUTUGATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S AIRPORT DR STE 1
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-6649
Mailing Address - Country:US
Mailing Address - Phone:956-969-2904
Mailing Address - Fax:956-969-1650
Practice Address - Street 1:902 S AIRPORT DR STE 1
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6649
Practice Address - Country:US
Practice Address - Phone:956-969-2904
Practice Address - Fax:956-969-1650
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9139208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117052OtherSUPERIOR HEALTH PLANS
TX85M551OtherBC/BS OF TEXAS
TX85M551OtherBC/BS OF TEXAS