Basic Information
| Provider Information | |||||||||
| NPI: | 1619478567 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TYLER J ROUBIDOUX MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Practice Location | |||||||||
| Address1: | 11645 WILSHIRE BLVD STE 987 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900256814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103939359 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROUBIDOUX | ||||||||
| AuthorizedOfficialFirstName: | TYLER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2083053536 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A127481 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.