Provider Demographics
NPI:1003176801
Name:TUDTUD, RISA BOOC
Entity Type:Individual
Prefix:MRS
First Name:RISA
Middle Name:BOOC
Last Name:TUDTUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10760 N MAGNOLIA AVE
Mailing Address - Street 2:8B
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-1292
Mailing Address - Country:US
Mailing Address - Phone:858-537-7007
Mailing Address - Fax:
Practice Address - Street 1:10760 N MAGNOLIA AVE
Practice Address - Street 2:8B
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-1292
Practice Address - Country:US
Practice Address - Phone:858-537-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA748247261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty