Provider Demographics
NPI:1144327032
Name:ROMAN, RICARDO RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:RICHARD
Last Name:ROMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:ROMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4708 EAGLE ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGLE ROCK
Mailing Address - State:CA
Mailing Address - Zip Code:90041-2712
Mailing Address - Country:US
Mailing Address - Phone:323-254-3700
Mailing Address - Fax:323-254-3701
Practice Address - Street 1:4708 EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE ROCK
Practice Address - State:CA
Practice Address - Zip Code:90041-2712
Practice Address - Country:US
Practice Address - Phone:323-254-3700
Practice Address - Fax:323-254-3701
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79013207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH92224Medicare UPIN