Basic Information
| Provider Information | |||||||||
| NPI: | 1518945658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESRUISSEAU | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3569 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073033600 | ||||||||
| FaxNumber: | 7073033611 | ||||||||
| Practice Location | |||||||||
| Address1: | 3569 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073033600 | ||||||||
| FaxNumber: | 7073033611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 04/19/2011 | ||||||||
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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 | 207RI0200X | C54607 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 38871 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 3897593 | 05 | TN | MEDICAID |