Healthcare Provider Details

I. General information

NPI: 1164179586
Provider Name (Legal Business Name): OLGA JANE ROTERMUND NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2022
Last Update Date: 03/05/2022
Certification Date: 03/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 DOVER DR
WALNUT CREEK CA
94598-3322
US

IV. Provider business mailing address

210 DOVER DR
WALNUT CREEK CA
94598-3322
US

V. Phone/Fax

Practice location:
  • Phone: 925-787-4110
  • Fax:
Mailing address:
  • Phone: 925-787-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberG3944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: