Healthcare Provider Details

I. General information

NPI: 1235492489
Provider Name (Legal Business Name): MITCH RATANASEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-2201
US

IV. Provider business mailing address

2516 STOCKTON BLVD
SACRAMENTO CA
95817-2208
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2011
  • Fax:
Mailing address:
  • Phone: 916-734-2428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA128007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: