Provider Demographics
NPI:1225128994
Name:RUDOMETKIN, NATHAN JEROME (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JEROME
Last Name:RUDOMETKIN
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 1:24361 EL TORO RD STE 160
Mailing Address - Street 2:
Mailing Address - City:LAGUNA WOODS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-8897
Mailing Address - Country:US
Mailing Address - Phone:949-534-4000
Mailing Address - Fax:
Practice Address - Street 1:24361 EL TORO RD STE 160
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-8897
Practice Address - Country:US
Practice Address - Phone:949-534-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60929372207W00000X
CAA81443207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95506721Medicaid
CA00A814430Medicaid
I42356Medicare UPIN
CA00A814430Medicaid