Provider Demographics
NPI:1780746107
Name:PIERCE, JEFFREY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:PIERCE
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 1:1026 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5112
Mailing Address - Country:US
Mailing Address - Phone:707-583-9772
Mailing Address - Fax:
Practice Address - Street 1:440 S E ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5136
Practice Address - Country:US
Practice Address - Phone:707-583-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780746107Medicaid
CA1780746107Medicaid