MEDICARE: DR. ROME JUTABHA M.D.

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	174400000X	Specialist	G68613	CA
2	207RG0100X	Gastroenterology Physician	G68613	CA

General Provider Information

NPI Number	:	1790785434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROME JUTABHA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 31309
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-0309
Country	:	US
Telephone Number	:	323-442-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 SAN PABLO ST STE 1000
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-5312
Country	:	US
Telephone Number	:	323-442-5100
Fax Number	:

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

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	12/04/2020

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