MEDICARE: TYLER J ROUBIDOUX MD PC

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	207L00000X	Anesthesiology Physician	A127481	CA

General Provider Information

NPI Number	:	1619478567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TYLER J ROUBIDOUX MD PC

Provider Business Mailing Address
First Line	:	PO BOX 7001
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91357-7001
Country	:	US
Telephone Number	:	818-888-7815
Fax Number	:	818-715-1722

Provider Business Practice Location Address
First Line	:	11645 WILSHIRE BLVD STE 987
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6814
Country	:	US
Telephone Number	:	310-393-9359
Fax Number	:

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	TYLER J ROUBIDOUX
Credential	:	MD
Telephone Number	:	208-305-3536

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	04/25/2018

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