Healthcare Provider Details

I. General information

NPI: 1669507752
Provider Name (Legal Business Name): CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 E ALLUVIAL AVE SUITE 101
FRESNO CA
93720-2686
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 559-431-6226
  • Fax: 559-440-9005
Mailing address:
  • Phone: 559-443-2682
  • Fax: 559-443-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KARL P VAN GUNDY
Title or Position: PRESIDENT
Credential: MD
Phone: 559-453-5200