Provider Demographics
NPI:1730159815
Name:EZHUTHACHAN, RUTU S (MD)
Entity type:Individual
Prefix:
First Name:RUTU
Middle Name:S
Last Name:EZHUTHACHAN
Suffix:
Gender:F
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-560-2879
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:4475 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7826
Practice Address - Country:US
Practice Address - Phone:702-737-1880
Practice Address - Fax:702-259-4634
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10466208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2018853Medicaid
NV3102853Medicaid
NV1730159815Medicaid
H83082Medicare UPIN
NV1730159815Medicaid