Provider Demographics
NPI:1619956489
Name:RUPP, RICHARD L
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:RUPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E CHEVY CHASE DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4197
Mailing Address - Country:US
Mailing Address - Phone:818-247-0523
Mailing Address - Fax:818-247-2945
Practice Address - Street 1:1560 E CHEVY CHASE DR STE 330
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206
Practice Address - Country:US
Practice Address - Phone:818-247-0523
Practice Address - Fax:818-247-2945
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2014213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T11134Medicare UPIN
E2014Medicare ID - Type Unspecified
CA4832100001Medicare NSC