Provider Demographics
NPI:1720261118
Name:RUSSELL A. GROOTEGOED DPM
Entity Type:Organization
Organization Name:RUSSELL A. GROOTEGOED DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GROOTEGOED
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-833-3583
Mailing Address - Street 1:601 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3107
Mailing Address - Country:US
Mailing Address - Phone:310-833-3583
Mailing Address - Fax:
Practice Address - Street 1:601 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3107
Practice Address - Country:US
Practice Address - Phone:310-833-3583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2064335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E2064000Medicaid
CA=========OtherBLUE CROSS
CAE2064Medicare PIN
CAT11163Medicare UPIN
CA000E2064000Medicaid