Healthcare Provider Details

I. General information

NPI: 1164563862
Provider Name (Legal Business Name): THE PEDIATRI MEDICAL GROUP OF WATSONVILLE , INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 GREEN VALLEY RD
FREEDOM CA
95019-3136
US

IV. Provider business mailing address

222 GREEN VALLEY RD
FREEDOM CA
95019-3136
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-2969
  • Fax: 831-722-9604
Mailing address:
  • Phone: 831-728-2969
  • Fax: 831-722-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY A ROISMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 831-728-2969