Provider Demographics
NPI:1366678906
Name:STALLWORTH, ROXANNA (MD, MPH)
Entity type:Individual
Prefix:
First Name:ROXANNA
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:
Credentials:MD, MPH
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:
Other - Last Name:STALLWORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1640 NEWPORT BLVD STE 440
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3786
Mailing Address - Country:US
Mailing Address - Phone:949-791-8888
Mailing Address - Fax:
Practice Address - Street 1:1640 NEWPORT BLVD STE 440
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-791-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113706207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine