Healthcare Provider Details

I. General information

NPI: 1962864710
Provider Name (Legal Business Name): ELISABETH BEDOLLA ROCHA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISABETH ROCHA ESCOBAR

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 AIRWAY DR STE 202
SANTA ROSA CA
95403-1671
US

IV. Provider business mailing address

PO BOX 1870
WATSONVILLE CA
95077-1870
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-3600
  • Fax:
Mailing address:
  • Phone: 831-728-0222
  • Fax: 831-707-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number150730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: