Healthcare Provider Details

I. General information

NPI: 1356616619
Provider Name (Legal Business Name): ROSS GREGORY GAUDET M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

PO BOX 527
LARKSPUR CA
94977-0527
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-7100
  • Fax:
Mailing address:
  • Phone: 504-782-1362
  • Fax: 903-787-5854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number288790
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number163250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: