Provider Demographics
NPI:1588650162
Name:DUTRA, TIMOTHY GEORGE (DPM)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GEORGE
Last Name:DUTRA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13847 E 14TH ST
Mailing Address - Street 2:#110A
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2632
Mailing Address - Country:US
Mailing Address - Phone:510-351-7122
Mailing Address - Fax:510-351-1797
Practice Address - Street 1:13847 E 14TH ST
Practice Address - Street 2:#110A
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2632
Practice Address - Country:US
Practice Address - Phone:510-351-7122
Practice Address - Fax:510-351-1797
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE33830207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT11665Medicare UPIN