Healthcare Provider Details

I. General information

NPI: 1093706590
Provider Name (Legal Business Name): BRAD WILLIAM RUETENIK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 DEVONSHIRE DR SUITE F
ENCINITAS CA
92024-5136
US

IV. Provider business mailing address

249 S HIGHWAY 101 SUITE 408
SOLANA BEACH CA
92075-1807
US

V. Phone/Fax

Practice location:
  • Phone: 760-753-1804
  • Fax: 760-942-1890
Mailing address:
  • Phone: 760-753-1804
  • Fax: 760-942-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberE3866
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: