Provider Demographics
NPI:1841237658
Name:ROLDAN, MARIO A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:A
Last Name:ROLDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4314 W PRATT AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3535
Mailing Address - Country:US
Mailing Address - Phone:847-679-0494
Mailing Address - Fax:773-276-3179
Practice Address - Street 1:1044 N MOZART ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2789
Practice Address - Country:US
Practice Address - Phone:888-676-5326
Practice Address - Fax:773-276-3179
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36050636207V00000X
IN01058156A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C43819Medicare UPIN