Provider Demographics
NPI:1144334616
Name:SANTA ROSA WALK-IN MEDICAL CENTER
Entity type:Organization
Organization Name:SANTA ROSA WALK-IN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUGGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-484-0095
Mailing Address - Street 1:4934 VERDUGO WAY
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8631
Mailing Address - Country:US
Mailing Address - Phone:805-484-0095
Mailing Address - Fax:805-388-2174
Practice Address - Street 1:4934 VERDUGO WAY
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8631
Practice Address - Country:US
Practice Address - Phone:805-484-0095
Practice Address - Fax:805-388-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F-34102Medicare UPIN
W12088Medicare ID - Type Unspecified