Provider Demographics
NPI:1316250525
Name:KOOLAEE, ROODABEH MICHELLE (DO)
Entity type:Individual
Prefix:
First Name:ROODABEH
Middle Name:MICHELLE
Last Name:KOOLAEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:12462 PUTNAM ST STE 402
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1049
Practice Address - Country:US
Practice Address - Phone:562-789-5461
Practice Address - Fax:562-789-4468
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015491207R00000X
CA20A12722207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CAGR0100430OtherGROUP MEDI-CAL