Healthcare Provider Details

I. General information

NPI: 1689037285
Provider Name (Legal Business Name): BRYAN GADDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 TESCONI CIR STE B
SANTA ROSA CA
95401-4691
US

IV. Provider business mailing address

480 TESCONI CIR STE B
SANTA ROSA CA
95401-4691
US

V. Phone/Fax

Practice location:
  • Phone: 707-206-7268
  • Fax: 707-206-7254
Mailing address:
  • Phone: 707-206-7268
  • Fax: 707-206-7254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberT-3120
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: