Provider Demographics
NPI:1770060204
Name:ESCOBAR ROLDAN, IVAN DARIO
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:DARIO
Last Name:ESCOBAR ROLDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVERFRONT BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8812
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:
Practice Address - Street 1:5325 26TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3012
Practice Address - Country:US
Practice Address - Phone:941-752-7173
Practice Address - Fax:941-567-6277
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246YC3302X
NC237864390200000X, 2084P0800X
FLME1553082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No246YC3302XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health InformationCoding Specialist, Physician Office Based
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program