Provider Demographics
NPI:1053763490
Name:CUTLER, BLAYNE
Entity type:Individual
Prefix:
First Name:BLAYNE
Middle Name:
Last Name:CUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12801 CROSSROADS PKWY S
Mailing Address - Street 2:12801 CROSSROADS PARKWAY, SUTE 200
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91746-3502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12801 CROSSROADS PKWY S
Practice Address - Street 2:12801 CROSSROADS PARKWAY, SUTE 200
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3502
Practice Address - Country:US
Practice Address - Phone:562-222-7896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC142571207RI0200X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease