Provider Demographics
NPI:1144906488
Name:GURROLA, ROXANNE JACKELYN (OD)
Entity type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:JACKELYN
Last Name:GURROLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3650 BARHAM BLVD APT T317
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1499
Mailing Address - Country:US
Mailing Address - Phone:818-751-3490
Mailing Address - Fax:
Practice Address - Street 1:1051 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1421
Practice Address - Country:US
Practice Address - Phone:818-841-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35540152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist