Healthcare Provider Details

I. General information

NPI: 1811990237
Provider Name (Legal Business Name): JASON CUNNINGHAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 PALM AVE SUITE C
SEBASTOPOL CA
95472-4269
US

IV. Provider business mailing address

PO BOX 1449
GUERNEVILLE CA
95446-1449
US

V. Phone/Fax

Practice location:
  • Phone: 707-824-9999
  • Fax: 707-824-2853
Mailing address:
  • Phone: 707-869-5977
  • Fax: 707-869-5983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8284
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: