Healthcare Provider Details

I. General information

NPI: 1104831247
Provider Name (Legal Business Name): DR. RAYMOND PLODKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL SUITE 317
SAN DIEGO CA
92130-3082
US

IV. Provider business mailing address

FILE # 54433
LOS ANGELES CA
90074-4433
US

V. Phone/Fax

Practice location:
  • Phone: 858-794-1250
  • Fax:
Mailing address:
  • Phone: 858-784-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number10287
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA64845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: