Healthcare Provider Details

I. General information

NPI: 1154377109
Provider Name (Legal Business Name): PHILIPPE EDOUARD, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

1275 4TH ST #371
SANTA ROSA CA
95404-4057
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-3210
  • Fax:
Mailing address:
  • Phone: 707-322-5679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC51257
License Number StateCA

VIII. Authorized Official

Name: PHILIPPE ROBERT EDOUARD
Title or Position: OWNER
Credential: M.D.
Phone: 707-322-5679