Basic Information
Provider Information | |||||||||
NPI: | 1245525088 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOERSAM | ||||||||
FirstName: | GERALD | ||||||||
MiddleName: | BENJAMIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DOERSAM | ||||||||
OtherFirstName: | GERALD | ||||||||
OtherMiddleName: | BENJAMIN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 830 SCENIC DR | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953506131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2095587164 | ||||||||
FaxNumber: | 2095588723 | ||||||||
Practice Location | |||||||||
Address1: | 830 SCENIC DR | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953506131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2095587164 | ||||||||
FaxNumber: | 2095588723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2011 | ||||||||
LastUpdateDate: | 06/09/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A49166 | CA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 08271 | ZZ | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.