Provider Demographics
NPI:1083656508
Name:RODIBAUGH, DAVID LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEONARD
Last Name:RODIBAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT RAPHAEL
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2761
Mailing Address - Country:US
Mailing Address - Phone:714-835-3709
Mailing Address - Fax:714-835-3287
Practice Address - Street 1:1100 N TUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3509
Practice Address - Country:US
Practice Address - Phone:714-835-6055
Practice Address - Fax:714-835-3287
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC331222085B0100X, 2085N0700X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C331220Medicaid
A35170Medicare UPIN
WC33122Medicare ID - Type Unspecified