Basic Information
| Provider Information | |||||||||
| NPI: | 1104269430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STORAGE | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | ROOSTA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROOSTA | ||||||||
| OtherFirstName: | TINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2625 W ALAMEDA AVE STE 322 | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188439015 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A132383 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | A132383 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.