1437134665 NPI number — ROBERT C WOLLMAN MD

Table of content: ROBERT C WOLLMAN MD (NPI 1437134665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437134665 NPI number — ROBERT C WOLLMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLLMAN
Provider First Name:
ROBERT
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1437134665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 512185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90051-0185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-775-3514
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1328 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90404-2032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-829-8913
Provider Business Practice Location Address Fax Number:
310-315-6168
Provider Enumeration Date:
12/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  G78624 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G786240 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: WG78624J . This is a "MEDICARE SP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 920001237 . This is a "RR MEDICARE - SJHC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WG78624E . This is a "MEDICARE SJMC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WG78624F . This is a "MEDICARE SJHC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WG78624I . This is a "MEDICARE LCM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WG78624K . This is a "MEDICARE SJO" identifier . This identifiers is of the category "OTHER".




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