1154315273 NPI number — DR. ELEBY RUDOLPH WASHINGTON III M.D.

Table of content: DR. ELEBY RUDOLPH WASHINGTON III M.D. (NPI 1154315273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154315273 NPI number — DR. ELEBY RUDOLPH WASHINGTON III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASHINGTON
Provider First Name:
ELEBY
Provider Middle Name:
RUDOLPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154315273
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4644 LINCOLN BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MARINA DEL REY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90292-6313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-577-8500
Provider Business Mailing Address Fax Number:
310-577-8507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4644 LINCOLN BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MARINA DEL REY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90292-6313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-577-8500
Provider Business Practice Location Address Fax Number:
310-577-8507
Provider Enumeration Date:
09/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G53301 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G533010 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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