Provider Demographics
NPI:1184649212
Name:RODARTE, GABRIEL (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:RODARTE
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 1:425 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3413
Mailing Address - Country:US
Mailing Address - Phone:760-520-8300
Mailing Address - Fax:760-737-2024
Practice Address - Street 1:425 N DATE ST
Practice Address - Street 2:#203
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3413
Practice Address - Country:US
Practice Address - Phone:760-520-8340
Practice Address - Fax:760-839-9459
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA879062084P0800X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20041ZOtherMEDICARE CLINIC PTAN
CAW14158OtherMEDICARE CLINIC PTAN
CAZZZ20041ZOtherMEDICARE CLINIC PTAN
CAI36453Medicare UPIN