Provider Demographics
NPI:1235275033
Name:BUCHANAN, RODNEY (PT)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 2ND ST STE 103
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5069
Mailing Address - Country:US
Mailing Address - Phone:310-477-0018
Mailing Address - Fax:310-954-9422
Practice Address - Street 1:1137 2ND ST STE 103
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5069
Practice Address - Country:US
Practice Address - Phone:310-477-0018
Practice Address - Fax:310-954-9422
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15886174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200811901OtherACS PROVIDER NUMBER
CAZZZ47212ZOtherBLUE SHIELD PROVIDER
CA954718855OtherBLUE CROSS PROVIDER