Provider Demographics
NPI:1639122757
Name:ROLLING OAKS RADIOLOGY MEDICAL CORP CORPORATION
Entity Type:Organization
Organization Name:ROLLING OAKS RADIOLOGY MEDICAL CORP CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-778-1513
Mailing Address - Street 1:1014 S WESTLAKE BLVD STE 14
Mailing Address - Street 2:PMB 114
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-3133
Mailing Address - Country:US
Mailing Address - Phone:805-778-1513
Mailing Address - Fax:805-267-5115
Practice Address - Street 1:415 ROLLING OAKS DR
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1029
Practice Address - Country:US
Practice Address - Phone:805-778-1513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ39119ZOtherBLUE SHIELD
ZZZ65592ZOtherBLUE SHIELD
CG2342OtherRAILROAD MEDICARE
CAGR0056260Medicaid