Provider Demographics
NPI:1851419410
Name:WARLITO G ROLLOLAZO
Entity Type:Organization
Organization Name:WARLITO G ROLLOLAZO
Other - Org Name:CENTER FOR GENERAL MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WARLITO
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROLLOLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-456-9993
Mailing Address - Street 1:809 W BANKHEAD HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1520
Mailing Address - Country:US
Mailing Address - Phone:770-456-9993
Mailing Address - Fax:770-456-9949
Practice Address - Street 1:809 W BANKHEAD HWY
Practice Address - Street 2:SUITE D
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1520
Practice Address - Country:US
Practice Address - Phone:770-456-9993
Practice Address - Fax:770-456-9949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17551208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA143087983AMedicaid
GA000114133GMedicaid
GAGRP7420Medicare ID - Type UnspecifiedGROUP NUMBER