Provider Demographics
NPI:1861525248
Name:RUTAR, TINA (MD)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:RUTAR
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 1:1408 E BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8279
Mailing Address - Country:US
Mailing Address - Phone:541-779-2020
Mailing Address - Fax:541-770-6838
Practice Address - Street 1:1408 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8279
Practice Address - Country:US
Practice Address - Phone:541-779-2020
Practice Address - Fax:541-770-6838
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89466207W00000X
ORMD160057207W00000X, 207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89466OtherLICENSE #
CA00894660OtherMEDI-CAL PPIN #
CA00894660OtherMEDI-CAL PPIN #