Healthcare Provider Details

I. General information

NPI: 1245525088
Provider Name (Legal Business Name): GERALD BENJAMIN DOERSAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GERALD BENJAMIN DOERSAM MD

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 SCENIC DR
MODESTO CA
95350-6131
US

IV. Provider business mailing address

830 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-7164
  • Fax: 209-558-8723
Mailing address:
  • Phone: 209-558-7164
  • Fax: 209-558-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA49166
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number08271
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: