Provider Demographics
NPI:1053430801
Name:SKUTTA, WILLIAM R (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:SKUTTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:823 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1889
Mailing Address - Country:US
Mailing Address - Phone:815-786-6393
Mailing Address - Fax:815-786-6724
Practice Address - Street 1:823 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1889
Practice Address - Country:US
Practice Address - Phone:815-786-6393
Practice Address - Fax:815-786-6724
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04006493152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT35335Medicare UPIN
ILK19938Medicare PIN