1720311400 NPI number — DR. WILLIAM EDWARD RIETKERK MD MBA

Table of content: DR. WILLIAM EDWARD RIETKERK MD MBA (NPI 1720311400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720311400 NPI number — DR. WILLIAM EDWARD RIETKERK MD MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIETKERK
Provider First Name:
WILLIAM
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD MBA
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:
1720311400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 ROLLING OAKS DRIVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-497-7529
Provider Business Mailing Address Fax Number:
805-494-3486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 ROLLING OAKS DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOUSAND OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91361-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-661-3376
Provider Business Practice Location Address Fax Number:
212-661-3366
Provider Enumeration Date:
09/11/2009

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: 207N00000X , with the licence number:  A141249 , 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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