MEDICARE: DR. ELLENBETH GROSSNICKLE RODARTE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A76932	CA

General Provider Information

NPI Number	:	1205808714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLENBETH GROSSNICKLE RODARTE M.D.

Provider Business Mailing Address
First Line	:	2600 VIA DE LA VALLE
Second Line	:	STE 200
City	:	DEL MAR
State	:	CA
Zip	:	92014-1992
Country	:	US
Telephone Number	:	858-499-2708
Fax Number	:	858-309-3269

Provider Business Practice Location Address
First Line	:	2600 VIA DE LA VALLE
Second Line	:	STE 200
City	:	DEL MAR
State	:	CA
Zip	:	92014-1992
Country	:	US
Telephone Number	:	858-499-2708
Fax Number	:	858-309-3269

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	06/06/2014

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