Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | A130427 | CA |
N | 2086S0129X | Vascular Surgeon | MD60748391 | WA |
NPI | 1104185644 |
---|---|
Provider Name | Johnathon Curtis Rollo |
First Address | Los Angeles, CA 90045-5631 |
Second Address | Los Angeles, CA 90095-8414 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2012 |
Last Update Date | 02/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1104185644 | (05) | WA |
8967381 | MEDICARE PIN (01) | WA |