Provider Demographics
NPI:1710053160
Name:CONGBALAY, ROLANDO C (MD)
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:C
Last Name:CONGBALAY
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 1:985 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3109
Mailing Address - Country:US
Mailing Address - Phone:614-291-0022
Mailing Address - Fax:614-291-6687
Practice Address - Street 1:985 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3109
Practice Address - Country:US
Practice Address - Phone:614-291-0022
Practice Address - Fax:614-291-6687
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033387207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0224724Medicaid
OHA73956Medicare UPIN
OH0224724Medicaid