Healthcare Provider Details

I. General information

NPI: 1245267285
Provider Name (Legal Business Name): KEITH VINCENT RUNDLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W CHAPMAN AVE SUITE 203
ORANGE CA
92868-2872
US

IV. Provider business mailing address

1031 W CHAPMAN AVE STE 203
ORANGE CA
92868-2872
US

V. Phone/Fax

Practice location:
  • Phone: 714-558-2822
  • Fax: 714-835-3726
Mailing address:
  • Phone: 714-558-2822
  • Fax: 714-835-3726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG97929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: