Provider Demographics
NPI:1366795155
Name:RUTGARD, JEFFREY JAY (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAY
Last Name:RUTGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-717 KIPAPA DRIVE #23
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789
Mailing Address - Country:US
Mailing Address - Phone:808-888-6217
Mailing Address - Fax:
Practice Address - Street 1:95-717 KIPAPA DRIVE #23
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789
Practice Address - Country:US
Practice Address - Phone:808-888-6217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD16420207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology