Healthcare Provider Details

I. General information

NPI: 1700714821
Provider Name (Legal Business Name): PAUL LADEWIG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 WATERSTONE PL
SAN RAMON CA
94582-3022
US

IV. Provider business mailing address

1413 WATERSTONE PL
SAN RAMON CA
94582-3022
US

V. Phone/Fax

Practice location:
  • Phone: 616-214-1862
  • Fax:
Mailing address:
  • Phone: 616-214-1862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86030961
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: