Healthcare Provider Details

I. General information

NPI: 1023177680
Provider Name (Legal Business Name): GARY G. HUFFAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

393 E WALNUT ST 3RD FLOOR PHR SYSTEMS
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-353-2000
  • Fax:
Mailing address:
  • Phone: 626-405-3640
  • Fax: 626-405-6768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG29747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: