Healthcare Provider Details

I. General information

NPI: 1720142359
Provider Name (Legal Business Name): KRISTIARSI RUDITO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

11711 COLLETT AVE
RIVERSIDE CA
92505-3766
US

V. Phone/Fax

Practice location:
  • Phone: 951-353-5569
  • Fax:
Mailing address:
  • Phone: 951-785-5534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA75290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: