Provider Demographics
NPI:1396855292
Name:MOUNTAIN, RODERICK I (MD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:I
Last Name:MOUNTAIN
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 1:525 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5616
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:619-585-4390
Practice Address - Street 1:525 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5616
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-585-4390
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A528800Medicaid
CAWA52880PMedicare ID - Type Unspecified
CAG17946Medicare UPIN