Healthcare Provider Details

I. General information

NPI: 1598820219
Provider Name (Legal Business Name): JAMES EDWARD O'DORISIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
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
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA44147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: