Provider Demographics
NPI:1063664472
Name:KURNIADI, RACHEL (MD)
Entity Type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:
Last Name:KURNIADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 CAMINO DE LA SIESTA
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3116
Mailing Address - Country:US
Mailing Address - Phone:619-260-6300
Mailing Address - Fax:858-373-2447
Practice Address - Street 1:5030 CAMINO DE LA SIESTA
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3116
Practice Address - Country:US
Practice Address - Phone:619-260-6300
Practice Address - Fax:858-373-2447
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41752208100000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE50890Medicare UPIN
BT021ZMedicare PIN