Basic Information
| Provider Information | |||||||||
| NPI: | 1770060204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ESCOBAR ROLDAN | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | DARIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 RIVERFRONT BLVD STE 710 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417764000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5325 26TH ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342073012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417527173 | ||||||||
| FaxNumber: | 9415676277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2018 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246YC3302X | N | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Health Info | Coding Specialist, Physician Office Based | 390200000X | 237864 | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | ME155308 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 237864 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.