Provider Demographics
NPI:1629074406
Name:CARUTHERS, BERTRAM JR (MD)
Entity type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:
Last Name:CARUTHERS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4048 N 110TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-4488
Mailing Address - Country:US
Mailing Address - Phone:913-721-1001
Mailing Address - Fax:913-721-1012
Practice Address - Street 1:1734 E 63RD ST
Practice Address - Street 2:STE 470
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-5341
Practice Address - Country:US
Practice Address - Phone:816-333-6555
Practice Address - Fax:816-333-6564
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-25
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5307207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOS093719Medicare PIN