Provider Demographics
NPI:1447017488
Name:RYWELSKI, MARK JUDE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JUDE
Last Name:RYWELSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1599
Mailing Address - Country:US
Mailing Address - Phone:619-239-7370
Mailing Address - Fax:
Practice Address - Street 1:2980 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-1599
Practice Address - Country:US
Practice Address - Phone:619-239-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-PCLKWS175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty