1205808714 NPI number — DR. ELLENBETH GROSSNICKLE RODARTE M.D.

Table of content: DR. ELLENBETH GROSSNICKLE RODARTE M.D. (NPI 1205808714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205808714 NPI number — DR. ELLENBETH GROSSNICKLE RODARTE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODARTE
Provider First Name:
ELLENBETH
Provider Middle Name:
GROSSNICKLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1205808714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 VIA DE LA VALLE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
DEL MAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92014-1992
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-499-2708
Provider Business Mailing Address Fax Number:
858-309-3269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 VIA DE LA VALLE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
DEL MAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92014-1992
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-499-2708
Provider Business Practice Location Address Fax Number:
858-309-3269
Provider Enumeration Date:
02/07/2006

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: 207Q00000X , with the licence number:  A76932 , 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)





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