Provider Demographics
NPI:1164447082
Name:BERTOLDI, ROGER VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:VICTOR
Last Name:BERTOLDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 UCLA MEDICAL PLZ STE B200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-4008
Practice Address - Country:US
Practice Address - Phone:310-794-1195
Practice Address - Fax:310-794-7491
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA405192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A405190OtherMEDICAL PPIN #
CAA85462Medicare UPIN
CACA613ZMedicare PIN