Basic Information
| Provider Information | |||||||||
| NPI: | 1205071065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | JON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5344 S ARABIAN DR | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856509199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7057644102 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2008 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD2016-0801 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 539599YN90 | 01 | NM | MEDICARE PTAN | OTHER | 539599YLGQ | 01 | NM | MEDICARE PTAN | OTHER |