MEDICARE: DR. ANDREW JAMES DESRUISSEAU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	C54607	CA
2	207RI0200X	Infectious Disease Physician	38871	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518945658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW JAMES DESRUISSEAU M.D.

Provider Business Mailing Address
First Line	:	3569 ROUND BARN CIR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1757
Country	:	US
Telephone Number	:	707-303-3600
Fax Number	:	707-303-3611

Provider Business Practice Location Address
First Line	:	3569 ROUND BARN CIR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1757
Country	:	US
Telephone Number	:	707-303-3600
Fax Number	:	707-303-3611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	04/19/2011

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