Provider Demographics
NPI:1205808714
Name:RODARTE, ELLENBETH GROSSNICKLE (MD)
Entity type:Individual
Prefix:DR
First Name:ELLENBETH
Middle Name:GROSSNICKLE
Last Name:RODARTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2600 VIA DE LA VALLE
Mailing Address - Street 2:STE 200
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-1992
Mailing Address - Country:US
Mailing Address - Phone:858-499-2708
Mailing Address - Fax:858-309-3269
Practice Address - Street 1:2600 VIA DE LA VALLE
Practice Address - Street 2:STE 200
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-1992
Practice Address - Country:US
Practice Address - Phone:858-499-2708
Practice Address - Fax:858-309-3269
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA76932207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H92710Medicare UPIN