Healthcare Provider Details

I. General information

NPI: 1144764523
Provider Name (Legal Business Name): SANTA ROSA VEIN ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 SONOMA AVE STE 2
SANTA ROSA CA
95404-4813
US

IV. Provider business mailing address

990 SONOMA AVE SUITE 2
SANTA ROSA CA
95404-4813
US

V. Phone/Fax

Practice location:
  • Phone: 707-636-8346
  • Fax: 707-205-1008
Mailing address:
  • Phone: 707-636-8346
  • Fax: 707-205-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSE V BALLESTEROS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 707-636-8346