Healthcare Provider Details

I. General information

NPI: 1760607790
Provider Name (Legal Business Name): EASTERN SIERRA UROLOGY PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 PIONEER LN SUITE F
BISHOP CA
93514-2563
US

IV. Provider business mailing address

152 PIONEER LN SUITE F
BISHOP CA
93514-2563
US

V. Phone/Fax

Practice location:
  • Phone: 760-872-1606
  • Fax: 760-872-3463
Mailing address:
  • Phone: 760-872-1606
  • Fax: 760-872-3463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG67284
License Number StateCA

VIII. Authorized Official

Name: DR. TOMI L BORTOLAZZO
Title or Position: OWNER
Credential: M.D.
Phone: 760-872-1606