Provider Demographics
NPI:1730229014
Name:RUTBERG, LEONARD DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:DAVID
Last Name:RUTBERG
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 1:10201 MISSION GORGE RD
Mailing Address - Street 2:STE H
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3026
Mailing Address - Country:US
Mailing Address - Phone:619-596-4963
Mailing Address - Fax:619-596-4965
Practice Address - Street 1:10201 MISSION GORGE RD
Practice Address - Street 2:STE H
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3026
Practice Address - Country:US
Practice Address - Phone:619-596-4963
Practice Address - Fax:619-596-4965
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30089174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE89637Medicare UPIN
CAW2600Medicare ID - Type Unspecified