Healthcare Provider Details

I. General information

NPI: 1083997985
Provider Name (Legal Business Name): BARRY RODGVELLER DPM PODIATRY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 W 6TH ST SUITE 240
SAN PEDRO CA
90732-3514
US

IV. Provider business mailing address

1360 W 6TH ST SUITE 240
SAN PEDRO CA
90732-3514
US

V. Phone/Fax

Practice location:
  • Phone: 310-548-3311
  • Fax: 310-548-3384
Mailing address:
  • Phone: 310-548-3311
  • Fax: 310-548-3384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: BARRY RODGVELLER
Title or Position: PRESIDENT/OWNER
Credential: DPM
Phone: 310-548-3311