Healthcare Provider Details

I. General information

NPI: 1104898675
Provider Name (Legal Business Name): JOHN ELDRED DISIERE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 HARRISON AVE
EUREKA CA
95503-5638
US

IV. Provider business mailing address

3116 HARRISON AVE
EUREKA CA
95503-5638
US

V. Phone/Fax

Practice location:
  • Phone: 707-444-3885
  • Fax: 707-444-7843
Mailing address:
  • Phone: 707-444-3885
  • Fax: 707-444-7843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC42437
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: