Healthcare Provider Details

I. General information

NPI: 1801043799
Provider Name (Legal Business Name): RALPH EDWARD RETHERFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20405 LYONS BALD MTN RD
SONORA CA
95370-8780
US

IV. Provider business mailing address

PO BOX 4990
SONORA CA
95370-1990
US

V. Phone/Fax

Practice location:
  • Phone: 209-588-1424
  • Fax: 209-588-1521
Mailing address:
  • Phone: 209-588-1424
  • Fax: 209-588-1521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA24305
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberA24305
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA24305
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA24305
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA24305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: