Basic Information
Provider Information | |||||||||
NPI: | 1013939875 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCARBOROUGH | ||||||||
FirstName: | ROGER | ||||||||
MiddleName: | BRUCE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 TRANCAS STREET | ||||||||
Address2: | STE 209 | ||||||||
City: | NAPA | ||||||||
State: | CA | ||||||||
PostalCode: | 945582908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7072511850 | ||||||||
FaxNumber: | 7072261502 | ||||||||
Practice Location | |||||||||
Address1: | 1100 TRANCAS STREET | ||||||||
Address2: | STE 209 | ||||||||
City: | NAPA | ||||||||
State: | CA | ||||||||
PostalCode: | 945582908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7072511850 | ||||||||
FaxNumber: | 7072261502 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2006 | ||||||||
LastUpdateDate: | 11/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A35569 | CA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | GR0081501 | 01 | CA | MEDI-CAL | OTHER | GR0081500 | 05 | CA |   | MEDICAID |