=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396786547
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT L WIRTH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 09/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 ROWLAND WAY
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94945-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-209-1500
-----------------------------------------------------
Fax | 415-209-1501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6102
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94948-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-884-3418
-----------------------------------------------------
Fax | 415-883-0877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | G55313
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------