Provider Demographics
NPI:1205071065
Name:ROLLE, TIMOTHY JON (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JON
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 1:5344 S ARABIAN DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-9199
Mailing Address - Country:US
Mailing Address - Phone:705-764-4102
Mailing Address - Fax:
Practice Address - Street 1:8020 CONSTITUTION PL NE
Practice Address - Street 2:SUITE 202
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7607
Practice Address - Country:US
Practice Address - Phone:505-998-3096
Practice Address - Fax:505-998-3100
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-08012085R0202X
OH35-1212952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM539599YN90OtherMEDICARE PTAN
NM539599YLGQOtherMEDICARE PTAN