1134358534 NPI number — EDWARD E. ROTAN, JR., MD, P.A.

Table of content: (NPI 1134358534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134358534 NPI number — EDWARD E. ROTAN, JR., MD, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD E. ROTAN, JR., MD, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134358534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11726 SAN VICENTE BLVD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90049-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-255-2487
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 N FIELDER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76012-4695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-261-1626
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROTAN
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
951-255-2487

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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