Provider Demographics
NPI:1093706590
Name:RUETENIK, BRAD WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:WILLIAM
Last Name:RUETENIK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:249 S HIGHWAY 101
Mailing Address - Street 2:SUITE 408
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1807
Mailing Address - Country:US
Mailing Address - Phone:760-753-1804
Mailing Address - Fax:760-942-1890
Practice Address - Street 1:1011 DEVONSHIRE DR
Practice Address - Street 2:SUITE F
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5136
Practice Address - Country:US
Practice Address - Phone:760-753-1804
Practice Address - Fax:760-942-1890
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3866213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE3866AMedicare ID - Type Unspecified
CAU46740Medicare UPIN