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General NPI Number Information
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NPI Number | 1477891794
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Entity Type | Individual
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Provider Name | CLETUS GARY BODENSTEINER M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/21/2013
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Last Update Date | 01/21/2013
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Provider Practice Location Address
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Address Line | 230 HAEHL CREEK CT
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City | WILLITS
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State | CA
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Zip | 95490-5755
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Country | US
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Telephone | 707-459-2708
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Fax | 707-459-2804
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Provider Business Mailing Address
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Address Line | 230 HAEHL CREEK CT
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City | WILLITS
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State | CA
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Zip | 95490-5755
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Country | US
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Telephone | 707-459-2708
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Fax | 707-459-2804
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | G24841
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License Number State | CA
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