Provider Demographics
NPI:1609889120
Name:RYDELSKI, MISTY JAN (MD)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:JAN
Last Name:RYDELSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-1920
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-1920
Mailing Address - Country:US
Mailing Address - Phone:714-628-3200
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:1095 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3526
Practice Address - Country:US
Practice Address - Phone:714-449-4800
Practice Address - Fax:714-449-4956
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG075535207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75535Medicaid
CAG75535Medicaid
CAG75535Medicare ID - Type Unspecified