Healthcare Provider Details

I. General information

NPI: 1043412489
Provider Name (Legal Business Name): RICHARD H. ROE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 03/07/2023
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WILSHIRE BLVD 380
LOS ANGELES CA
90017-4810
US

IV. Provider business mailing address

1245 WILSHIRE BLVD 380
LOS ANGELES CA
90017-4810
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-8810
  • Fax: 213-481-1503
Mailing address:
  • Phone: 213-483-8810
  • Fax: 213-481-1503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA95880
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA95880
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: