Healthcare Provider Details

I. General information

NPI: 1316997737
Provider Name (Legal Business Name): GARY FAUSONE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 HOSPITAL DR
UKIAH CA
95482-4531
US

IV. Provider business mailing address

275 HOSPITAL DR
UKIAH CA
95482-4531
US

V. Phone/Fax

Practice location:
  • Phone: 707-462-7900
  • Fax: 707-462-7947
Mailing address:
  • Phone: 707-462-7900
  • Fax: 707-462-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA64237
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: