Individual
RUSSELL A. GROOTEGOED
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
601 W 9TH ST, SAN PEDRO, CA 90731-3107
(310) 833-3583
(310) 833-1976
Mailing address
601 W 9TH ST, SAN PEDRO, CA 90731-3107
(310) 833-3583
(310) 833-1976
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
E2064
CA
335E00000X
Prosthetic/Orthotic Supplier
E2064
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000E2064000
—
CA
01
—
953239247
BLUE CROSS
CA
Enumeration date
06/13/2006
Last updated
04/11/2008
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