1841259041 NPI number — DR. MICHAEL DANA RUTTEN M.D.

Table of content: DR. MICHAEL DANA RUTTEN M.D. (NPI 1841259041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841259041 NPI number — DR. MICHAEL DANA RUTTEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTTEN
Provider First Name:
MICHAEL
Provider Middle Name:
DANA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
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:
1841259041
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:
1310 W. STEWART DR
Provider Second Line Business Mailing Address:
SUITE 607
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-3882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 W. STEWART DR
Provider Second Line Business Practice Location Address:
SUITE 607
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-3882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-639-4901
Provider Business Practice Location Address Fax Number:
714-771-5389
Provider Enumeration Date:
03/17/2006

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: 207RN0300X , with the licence number:  G078366 , 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: 00G783660 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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