Healthcare Provider Details

I. General information

NPI: 1083050041
Provider Name (Legal Business Name): JAMES E O'DORISIO MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BROOKWOOD AVE
SANTA ROSA CA
95404-4312
US

IV. Provider business mailing address

76 BROOKWOOD AVE
SANTA ROSA CA
95404-4312
US

V. Phone/Fax

Practice location:
  • Phone: 707-578-3000
  • Fax: 707-540-6407
Mailing address:
  • Phone: 707-578-3000
  • Fax: 707-540-6407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA44147
License Number StateCA

VIII. Authorized Official

Name: JAMES E. O'DORISIO
Title or Position: OWNER
Credential: MD
Phone: 707-578-3000