Provider Demographics
NPI:1083997985
Name:BARRY RODGVELLER DPM PODIATRY CORPORATION
Entity Type:Organization
Organization Name:BARRY RODGVELLER DPM PODIATRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGVELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-548-3311
Mailing Address - Street 1:1360 W 6TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-548-3311
Mailing Address - Fax:310-548-3384
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-548-3311
Practice Address - Fax:310-548-3384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty