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General NPI Number Information
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NPI Number | 1568669992
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Entity Type | Individual
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Provider Name | RODERICK DEAN PONATH M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/29/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 17291 IRVINE BLVD SUITE 104
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City | TUSTIN
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State | CA
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Zip | 92780-2941
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Country | US
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Telephone | 415-990-2502
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Fax | 415-461-2915
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Provider Business Mailing Address
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Address Line | PO BOX 447
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City | SAN QUENTIN
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State | CA
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Zip | 94964-0447
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Country | US
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Telephone | 415-990-2502
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Fax | 415-461-2931
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | A25415
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License Number State | CA
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