Healthcare Provider Details

I. General information

NPI: 1790700532
Provider Name (Legal Business Name): THOMAS DUCKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 DOYLE PARK DR STE 303
SANTA ROSA CA
95405-4559
US

IV. Provider business mailing address

500 DOYLE PARK DR STE 303
SANTA ROSA CA
95405-4559
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-1833
  • Fax: 707-575-3561
Mailing address:
  • Phone: 707-575-1833
  • Fax: 707-575-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG58176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: