Provider Demographics
NPI:1972598613
Name:ROLLE, CHARLES JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:ROLLE
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 1:294 W HWY 89A
Mailing Address - Street 2:SUITE 203
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3754
Mailing Address - Country:US
Mailing Address - Phone:928-639-5577
Mailing Address - Fax:928-639-5578
Practice Address - Street 1:294 W HWY 89A
Practice Address - Street 2:SUITE 203
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3754
Practice Address - Country:US
Practice Address - Phone:928-639-5577
Practice Address - Fax:928-639-5578
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7939174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102002Medicare ID - Type UnspecifiedYAVAPAI COUNTY
AZ102003Medicare ID - Type UnspecifiedCOCONINO COUNTY
AZD37531Medicare UPIN