Healthcare Provider Details

I. General information

NPI: 1053525113
Provider Name (Legal Business Name): R MITCHELL HISEROTE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 MCGINNIS CIR
COTATI CA
94931-7718
US

IV. Provider business mailing address

648 MCGINNIS CIR
COTATI CA
94931-7718
US

V. Phone/Fax

Practice location:
  • Phone: 559-999-8647
  • Fax:
Mailing address:
  • Phone: 559-999-8647
  • Fax: 707-824-8766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A7465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: