Healthcare Provider Details

I. General information

NPI: 1023103678
Provider Name (Legal Business Name): DORENE LYNNE OPAVA-RUTTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD VA DEPT OF PM&RS W117
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

11301 WILSHIRE BLVD VA DEPT OF PM&RS W117
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax: 310-268-4935
Mailing address:
  • Phone: 310-478-3711
  • Fax: 310-268-4935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG75244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: