MEDICARE: DR. JEFFRY D CARDNEAU MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	24944	OR
2	2086S0129X	Vascular Surgery Physician	A77313	CA

General Provider Information

NPI Number	:	1174528889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFRY D CARDNEAU MD

Provider Business Mailing Address
First Line	:	99 MONTECILLO RD
Second Line	:	MOB 1, 2ND FLOOR DEPARTMENT OF SURGERY
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-3308
Country	:	US
Telephone Number	:	415-444-2197
Fax Number	:

Provider Business Practice Location Address
First Line	:	99 MONTECILLO RD
Second Line	:	MOB 1, 2ND FLOOR, DEPARTMENT OF SURGERY
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-3308
Country	:	US
Telephone Number	:	415-444-3131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	12/09/2021

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