Basic Information
| Provider Information | |||||||||
| NPI: | 1447232822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOLANZ | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21552 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 9492631639 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 TORRANCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103035750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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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 | G55707 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | G55707 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G557070 | 05 | CA | MEDICAID | 00G557070 | 01 | CA | BLUE SHIELD | OTHER |