Healthcare Provider Details

I. General information

NPI: 1548334006
Provider Name (Legal Business Name): BRUCE D. GAYNOR, M.D., MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 HOEN AVE
SANTA ROSA CA
95405-7867
US

IV. Provider business mailing address

4720 HOEN AVE
SANTA ROSA CA
95405-7867
US

V. Phone/Fax

Practice location:
  • Phone: 707-527-8222
  • Fax:
Mailing address:
  • Phone: 707-527-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License NumberG84535
License Number StateCA

VIII. Authorized Official

Name: DR. BRUCE DAVID GAYNOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 707-527-8222