Provider Demographics
NPI:1518916089
Name:CORTEZ, ALLEN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:WILLIAM
Last Name:CORTEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-523-0616
Practice Address - Street 1:1701 4TH ST
Practice Address - Street 2:STE 200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3601
Practice Address - Country:US
Practice Address - Phone:707-579-2100
Practice Address - Fax:707-523-0616
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76718208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G767181Medicaid
CAP00469229OtherRR MEDICARE
CA00G767180OtherBS OF CALIFORNIA
CA00G767180Medicaid
F85822Medicare UPIN
CA00G767181Medicaid
CA00G767182Medicare PIN
CA00G767180OtherBS OF CALIFORNIA