MEDICARE: ROODABEH MICHELLE KOOLAEE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	OS015491	PA
2	207RR0500X	Rheumatology Physician	20A12722	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	W18762	OTHER	CA	GROUP MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1902846306	OTHER	CA	GROUP NPI
3	GR0100430	OTHER	CA	GROUP MEDI-CAL

General Provider Information

NPI Number	:	1316250525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROODABEH MICHELLE KOOLAEE DO

Provider Business Mailing Address
First Line	:	833 PARKMAN DR
Second Line	:
City	:	LA CANADA
State	:	CA
Zip	:	91011-2547
Country	:	US
Telephone Number	:	301-602-0816
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 FAIRMOUNT AVE STE 210
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91105-3152
Country	:	US
Telephone Number	:	808-531-4274
Fax Number	:	833-438-1648

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	10/24/2025

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