Provider Demographics
NPI:1598755159
Name:RODGVELLER, BARRY NEAL (DPM)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:NEAL
Last Name:RODGVELLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 W 6TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3589
Mailing Address - Country:US
Mailing Address - Phone:310-548-3311
Mailing Address - Fax:310-548-3384
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3589
Practice Address - Country:US
Practice Address - Phone:310-548-3311
Practice Address - Fax:310-548-3384
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1681213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E16810Medicaid
CA000E16810Medicaid
CA0218210001Medicare NSC
T11031Medicare UPIN