Provider Demographics
NPI:1518945658
Name:DESRUISSEAU, ANDREW JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JAMES
Last Name:DESRUISSEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3569 ROUND BARN CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1757
Mailing Address - Country:US
Mailing Address - Phone:707-303-3600
Mailing Address - Fax:707-303-3611
Practice Address - Street 1:3569 ROUND BARN CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1757
Practice Address - Country:US
Practice Address - Phone:707-303-3600
Practice Address - Fax:707-303-3611
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC54607207RI0200X
TN38871207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3897593Medicaid
TN3897593Medicaid
TNH85538Medicare UPIN