Healthcare Provider Details

I. General information

NPI: 1497725402
Provider Name (Legal Business Name): JEFFREY A ROISMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/09/2007
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 NumberG040506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: