Provider Demographics
NPI:1437134665
Name:WOLLMAN, ROBERT C (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:WOLLMAN
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:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:626-775-3514
Mailing Address - Fax:
Practice Address - Street 1:1328 22ND ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2032
Practice Address - Country:US
Practice Address - Phone:310-829-8913
Practice Address - Fax:310-315-6168
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG786242085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G786240Medicaid
CAWG78624JOtherMEDICARE SP
CA920001237OtherRR MEDICARE - SJHC
CAWG78624EOtherMEDICARE SJMC
CAWG78624FOtherMEDICARE SJHC
CAWG78624IOtherMEDICARE LCM
WG78624KOtherMEDICARE SJO
CAF76863Medicare UPIN
CAWG78624IOtherMEDICARE LCM