Provider Demographics
NPI:1154320836
Name:PROTACIO, RODOLFO BAGUINGUITO (MD)
Entity type:Individual
Prefix:DR
First Name:RODOLFO
Middle Name:BAGUINGUITO
Last Name:PROTACIO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S CENTRAL AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2785
Mailing Address - Country:US
Mailing Address - Phone:818-500-8739
Mailing Address - Fax:818-500-0957
Practice Address - Street 1:1500 S CENTRAL AVE STE 108
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2785
Practice Address - Country:US
Practice Address - Phone:818-500-8739
Practice Address - Fax:818-500-0957
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2025-04-24
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
CAA49837207R00000X, 207RG0300X
CAA049837207R00000X
CAA49873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A498370Medicaid
CA00A498370Medicaid
CAA49837Medicare ID - Type Unspecified