Provider Demographics
NPI:1366627788
Name:JOHN PHILLIP HURWITZ MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JOHN PHILLIP HURWITZ MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HURWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:707-583-1805
Mailing Address - Street 1:122 CALISTOGA RD
Mailing Address - Street 2:SUITE 197
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3751 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-5214
Practice Address - Country:US
Practice Address - Phone:707-583-1805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2OA6856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9645038Medicaid
CA9645038Medicaid