Provider Demographics
NPI:1194767921
Name:GROOTEGOED, RUSSELL A (DPM)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
Last Name:GROOTEGOED
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:310-833-1976
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:310-833-1976
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2064213ES0103X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953239247OtherBLUE CROSS
CA000E2064000Medicaid
CAE2064Medicare PIN
CAT11163Medicare UPIN
CA000E2064000Medicaid