Basic Information
| Provider Information | |||||||||
| NPI: | 1518940519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROSBE | ||||||||
| FirstName: | HERBERT | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HOEN AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954057824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075421611 | ||||||||
| FaxNumber: | 7075429958 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 HOEN AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954057824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075421611 | ||||||||
| FaxNumber: | 7075429958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G28047 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G280470 | 05 | CA | MEDICAID |