Provider Demographics
NPI:1811089717
Name:BERTOLLI, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:BERTOLLI
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:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:LAYTONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95454-0870
Mailing Address - Country:US
Mailing Address - Phone:707-984-6131
Mailing Address - Fax:707-984-7337
Practice Address - Street 1:50 BRANSCOMB ROAD
Practice Address - Street 2:
Practice Address - City:LAYTONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95454
Practice Address - Country:US
Practice Address - Phone:707-984-6131
Practice Address - Fax:707-984-7337
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03906FMedicaid
CA051907Medicare Oscar/Certification
CAA28734Medicare UPIN