Provider Demographics
NPI:1558849661
Name:DEROSE, SONJA (MD)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:
Last Name:DEROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SONJA
Other - Middle Name:
Other - Last Name:BRANDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:FORESTHILL
Mailing Address - State:CA
Mailing Address - Zip Code:95631-0279
Mailing Address - Country:US
Mailing Address - Phone:580-504-7043
Mailing Address - Fax:
Practice Address - Street 1:15230 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8107
Practice Address - Country:US
Practice Address - Phone:707-995-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG151475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine