Provider Demographics
NPI:1548722416
Name:R. MITCHELL HISEROTE DO, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:R. MITCHELL HISEROTE DO, PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:HISEROTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:707-329-6582
Mailing Address - Street 1:648 MCGINNIS CIR
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-7718
Mailing Address - Country:US
Mailing Address - Phone:559-999-8647
Mailing Address - Fax:707-329-6372
Practice Address - Street 1:7064 CORLINE CT STE C1
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4528
Practice Address - Country:US
Practice Address - Phone:707-329-6582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty