Provider Demographics
NPI:1083050041
Name:JAMES E O'DORISIO MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JAMES E O'DORISIO MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:O'DORISIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-578-3000
Mailing Address - Street 1:76 BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4312
Mailing Address - Country:US
Mailing Address - Phone:707-578-3000
Mailing Address - Fax:707-540-6407
Practice Address - Street 1:76 BROOKWOOD AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4312
Practice Address - Country:US
Practice Address - Phone:707-578-3000
Practice Address - Fax:707-540-6407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44147208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty