Provider Demographics
NPI:1285786889
Name:CUTLER, KENNETH WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:CUTLER
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:PO BOX 10047
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96162-0047
Mailing Address - Country:US
Mailing Address - Phone:530-448-1798
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9561
Practice Address - Country:US
Practice Address - Phone:530-265-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 70200208000000X
CAG070200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG070200OtherSTATE LICENSE NUMBER
NVNV 7240OtherSTATE LICENSE NUMBER