Provider Demographics
NPI:1235372020
Name:RUTLEDGE, ISIS BURAKOM (LMT)
Entity Type:Individual
Prefix:MRS
First Name:ISIS
Middle Name:BURAKOM
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 ROSECRANS ST
Mailing Address - Street 2:#120
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2674
Mailing Address - Country:US
Mailing Address - Phone:619-323-4089
Mailing Address - Fax:
Practice Address - Street 1:4520 EXECUTIVE DR
Practice Address - Street 2:STE 225
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3018
Practice Address - Country:US
Practice Address - Phone:619-323-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4969171W00000X
CA68684171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor