Provider Demographics
NPI:1598820219
Name:O'DORISIO, JAMES EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:O'DORISIO
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 1:76 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
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44147208G00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00462712OtherRAILROAD MEDICARE
CA00A441470Medicaid
CA00A441470OtherBLUE SHIELD OF CALIFORNIA
P00462712OtherRAILROAD MEDICARE
CA00A441474Medicare PIN
CA00A441473Medicare PIN
CA00A441470Medicaid
CA00A441475Medicare PIN
CA00A441471Medicare PIN