Provider Demographics
NPI:1285771360
Name:RODRICKS, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:RODRICKS
Suffix:
Gender:M
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:PO BOX 2934 & ONE HALF BEVERLY GLEN CIRCLE
Mailing Address - Street 2:#308
Mailing Address - City:BEL AIR
Mailing Address - State:CA
Mailing Address - Zip Code:90077
Mailing Address - Country:US
Mailing Address - Phone:760-772-8357
Mailing Address - Fax:760-772-8406
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:#1280
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-782-2164
Practice Address - Fax:818-782-5330
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84064207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285771360Medicaid
CAG58711Medicare UPIN
CA1285771360Medicaid
CAAN956XMedicare PIN