Provider Demographics
NPI:1245525088
Name:DOERSAM, GERALD BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:BENJAMIN
Last Name:DOERSAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GERALD
Other - Middle Name:BENJAMIN
Other - Last Name:DOERSAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:830 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-558-7164
Mailing Address - Fax:209-558-8723
Practice Address - Street 1:830 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-558-7164
Practice Address - Fax:209-558-8723
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49166207V00000X
ZZ08271207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology