Provider Demographics
NPI:1134166697
Name:RETTENMAIER, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:RETTENMAIER
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 1:1010 W LA VETA AVE STE 775
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4306
Mailing Address - Country:US
Mailing Address - Phone:714-749-2330
Mailing Address - Fax:949-831-1624
Practice Address - Street 1:1010 W LA VETA AVE
Practice Address - Street 2:STE 775
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4306
Practice Address - Country:US
Practice Address - Phone:949-705-9015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32692207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A326920Medicaid
CA00A326920Medicaid