Provider Demographics
NPI:1194766311
Name:ROLLO, ROBERT O (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:O
Last Name:ROLLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 BAREFOOT PARK LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2148
Mailing Address - Country:US
Mailing Address - Phone:979-219-1263
Mailing Address - Fax:
Practice Address - Street 1:3563 FAR WEST BLVD STE 110
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3029
Practice Address - Country:US
Practice Address - Phone:512-846-6925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2273207Q00000X, 207P00000X
LA340027207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S2460OtherBCBS
TX137215314Medicaid
TX8P6794OtherBCBS
TX137215313Medicaid
TX171711802Medicaid
TX137215314Medicaid
TX8D9089Medicare PIN
TX137215313Medicaid
TX00164YMedicare PIN
TX171711802Medicaid