MEDICARE: DR. ROMA TICKOO M.D., M.P.H.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	C164731	CA
2	208VP0000X	Pain Medicine Physician	237401	NY
3	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician	C164731	CA

General Provider Information

NPI Number	:	1326235995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROMA TICKOO M.D., M.P.H.

Provider Business Mailing Address
First Line	:	4140 W 190TH ST
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90504-5513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11800 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6602
Country	:	US
Telephone Number	:	310-582-7900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	04/13/2023

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