Provider Demographics
NPI:1851337950
Name:VAN DISSEL, GHISLAINE N S (DO)
Entity Type:Individual
Prefix:
First Name:GHISLAINE
Middle Name:N S
Last Name:VAN DISSEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 SNYDER LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2915
Mailing Address - Country:US
Mailing Address - Phone:707-585-8347
Mailing Address - Fax:707-585-8056
Practice Address - Street 1:5300 SNYDER LN
Practice Address - Street 2:SUITE A
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2915
Practice Address - Country:US
Practice Address - Phone:707-585-8347
Practice Address - Fax:707-585-8056
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX90610Medicaid
CA020A90610Medicare PIN