Healthcare Provider Details

I. General information

NPI: 1770100794
Provider Name (Legal Business Name): JUSTIN MAXWELL ROGOSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 16TH ST STE 2304
SANTA MONICA CA
90404-1249
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 855-488-9550
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA186595
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number186595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: