Provider Demographics
NPI:1962516203
Name:RUTTI, PETER J (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:RUTTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:J
Other - Last Name:RUTTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2110 FOREST AVE
Mailing Address - Street 2:STE B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1469
Mailing Address - Country:US
Mailing Address - Phone:408-295-3433
Mailing Address - Fax:408-293-4872
Practice Address - Street 1:2110 FOREST AVE
Practice Address - Street 2:STE B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1469
Practice Address - Country:US
Practice Address - Phone:408-295-3433
Practice Address - Fax:408-293-4872
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36364207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C363640Medicaid
CA00C363640Medicaid
CA00C363640Medicare Oscar/Certification
CA00C363640Medicare PIN
0268150001Medicare NSC