Basic Information
| Provider Information | |||||||||
| NPI: | 1912925140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROLLER | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10720 E SOUTHERN AVE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803650050 | ||||||||
| FaxNumber: | 4803650049 | ||||||||
| Practice Location | |||||||||
| Address1: | 10720 E SOUTHERN AVE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803650050 | ||||||||
| FaxNumber: | 4803650049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
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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 | 208000000X | R4P75 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 42322 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 500496 | 05 | AZ | MEDICAID |