=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518980754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY O ROHAM DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 12/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 CAMINO DE LOS MARES SUITE # 103
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-248-1900
-----------------------------------------------------
Fax | 949-248-1956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 CAMINO DE LOS MARES SUITE # 103
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-248-1900
-----------------------------------------------------
Fax | 949-248-1956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 20A8040
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------