Provider Demographics
NPI:1750435624
Name:INTEGRATIVE MEDICAL CLINIC OF SANTA ROSA, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:INTEGRATIVE MEDICAL CLINIC OF SANTA ROSA, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DOZOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-827-6312
Mailing Address - Street 1:3902 BONES RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-9754
Mailing Address - Country:US
Mailing Address - Phone:707-827-6312
Mailing Address - Fax:
Practice Address - Street 1:3902 BONES RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-9754
Practice Address - Country:US
Practice Address - Phone:707-827-6312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21170ZMedicare PIN