Basic Information
| Provider Information | |||||||||
| NPI: | 1235106428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUTINA | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24651 CENTER RIDGE RD | ||||||||
| Address2: | STE 350 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 25200 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441454141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403313047 | ||||||||
| FaxNumber: | 4403313084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 07/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 35043393K | OH | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1780634279 | 01 | GROUP NPI | OTHER | 0119204 | 01 | GROUP MEDICAID | OTHER | 10794581 | 01 | CAQH | OTHER | 0416437 | 05 | OH | MEDICAID | 9273172 | 01 | GROUP MEDICARE | OTHER | P00069300 | 01 | RR MEDICARE INDIVIDUAL | OTHER | 3610861 | 01 | GROUP ASC MEDICARE | OTHER | 120187 | 01 | KAISER | OTHER | CA4511 | 01 | RR MEDICARE GROUP | OTHER | D368301 | 01 | GROUP IND DIAGNOSTICS MED | OTHER |