Provider Demographics
NPI:1225018880
Name:ARCOVEDO, RODOLFO (MD)
Entity Type:Individual
Prefix:DR
First Name:RODOLFO
Middle Name:
Last Name:ARCOVEDO
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 1:786 3RD AVE, SUITE B
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-425-0797
Mailing Address - Fax:
Practice Address - Street 1:786 3RD AVE
Practice Address - Street 2:#B
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5826
Practice Address - Country:US
Practice Address - Phone:619-425-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51718208600000X
CA651718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0618203OtherTAX IDENTIFICATION
CAGROO62500OtherGROUP MEDICAID #
CA00C51718Medicaid
CAH26804Medicare UPIN
CAW13244Medicare PIN