Basic Information
| Provider Information | |||||||||
| NPI: | 1609840776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRESNAHAN | ||||||||
| FirstName: | W | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 986 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952580986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093399036 | ||||||||
| FaxNumber: | 2093391901 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCH CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | G55660 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 00G556601 | 05 | CA | MEDICAID |