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General NPI Number Information
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NPI Number | 1548334006
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Entity Type | Organization
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Legal Business Name | BRUCE D. GAYNOR, M.D., MEDICAL CORPORATION
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 4720 HOEN AVE
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City | SANTA ROSA
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State | CA
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Zip | 95405-7867
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Country | US
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Telephone | 707-527-8222
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Fax |
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Provider Business Mailing Address
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Address Line | 4720 HOEN AVE
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City | SANTA ROSA
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State | CA
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Zip | 95405-7867
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Country | US
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Telephone | 707-527-8222
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRUCE DAVID GAYNOR
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Credential | M.D.
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Telephone | 707-527-8222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 156FX1100X
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Taxonomy Name | Ophthalmic Technician/Technologist
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License Number | G84535
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License Number State | CA
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