| Doctor Name: | DR. WARLITO GULLA ROLLOLAZO |
| NPI Number: | 1871698522 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 17551 |
| Business Practice Address: | 809 W Hwy 78 Suite D Villa Rica, GA - 301801520 |
| Business Phone Number: | 7704569993 |
| Business Fax Number: | 7704569949 |
| Mailing Address: | 809 W Bankhead Hwy, Suite D VILLA RICA |
| State: | GA |
| Postal Code: | 301801520 |
| Phone Number: | 7704569993 |
| Fax Number: | 7704569949 |
| NPI Enumeration Date: | 09/14/2006 |
| NPI Last Update Date: | 01/04/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 17551 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |