1578546057 NPI number — DR. ROGER KENNETH STOLTZMAN M.D.

Table of content: DR. ROGER KENNETH STOLTZMAN M.D. (NPI 1578546057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578546057 NPI number — DR. ROGER KENNETH STOLTZMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOLTZMAN
Provider First Name:
ROGER
Provider Middle Name:
KENNETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1578546057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 W 14TH ST
Provider Second Line Business Mailing Address:
OAKLAND ARMY BASE
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94607-5031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-587-3427
Provider Business Mailing Address Fax Number:
510-587-3455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2505 W 14TH ST
Provider Second Line Business Practice Location Address:
OAKLAND ARMY BASE
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94607-5031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-587-3427
Provider Business Practice Location Address Fax Number:
510-587-3455
Provider Enumeration Date:
11/29/2005

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: 2084P0800X , with the licence number:  G41448 , 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)





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