Healthcare Provider Details

I. General information

NPI: 1477891794
Provider Name (Legal Business Name): CLETUS GARY BODENSTEINER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2013
Last Update Date: 01/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 HAEHL CREEK CT
WILLITS CA
95490-5755
US

IV. Provider business mailing address

230 HAEHL CREEK CT
WILLITS CA
95490-5755
US

V. Phone/Fax

Practice location:
  • Phone: 707-459-2708
  • Fax: 707-459-2804
Mailing address:
  • Phone: 707-459-2708
  • Fax: 707-459-2804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG24841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: