Provider Demographics
NPI:1902921737
Name:MICHAEL J KUTRYB MD PA
Entity Type:Organization
Organization Name:MICHAEL J KUTRYB MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUTRYB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-383-7888
Mailing Address - Street 1:2568 S RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-5980
Mailing Address - Country:US
Mailing Address - Phone:321-383-7888
Mailing Address - Fax:386-424-1401
Practice Address - Street 1:730 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4232
Practice Address - Country:US
Practice Address - Phone:321-267-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68787207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12051964OtherDATE OF BIRTH
FL12051964OtherDATE OF BIRTH
FLF38900Medicare UPIN
FL27322VMedicare ID - Type Unspecified