Provider Demographics
NPI:1245274125
Name:ROOHAN, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:ROOHAN
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 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:310-392-8636
Mailing Address - Fax:
Practice Address - Street 1:2509 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1828
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:310-392-6642
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G731040Medicaid
CA00G731040OtherMEDI-CAL
CAP01272656/DU4032OtherRAILROAD MEDICARE
CACA700WMedicare PIN
CAWG73104FMedicare PIN
CAP01272656/DU4032OtherRAILROAD MEDICARE
F63991Medicare UPIN
CACA700YMedicare PIN
CA00G731040OtherMEDI-CAL
CACA700V-EFF 3/16/13Medicare PIN