Provider Demographics
NPI:1053525113
Name:HISEROTE, R MITCHELL (DO)
Entity type:Individual
Prefix:DR
First Name:R
Middle Name:MITCHELL
Last Name:HISEROTE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:707-824-8766
Practice Address - Street 1:648 MCGINNIS CIR
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-7718
Practice Address - Country:US
Practice Address - Phone:559-999-8647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7465204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH29450Medicare UPIN