Basic Information
| Provider Information | |||||||||
| NPI: | 1851341176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINE | ||||||||
| FirstName: | RODGER | ||||||||
| MiddleName: | SETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4008 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033722740 | ||||||||
| FaxNumber: | 5033722754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095264500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G71194 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G711940 | 05 | CA | MEDICAID |