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NPI Code Detail

MEDICARE: BRUCE D. GAYNOR, M.D., MEDICAL CORPORATION

MEDICARE: BRUCE D. GAYNOR, M.D., MEDICAL CORPORATION
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
1332H00000XEyewear Supplier
2156FX1100XOphthalmic Technician/TechnologistG84535CA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1180041368OTHERCAMEDICARE RAILROAD

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1548334006
Entity Type Code : Organization
Provider Name (Legal Business Name) : BRUCE D. GAYNOR, M.D., MEDICAL CORPORATION
Provider Business Mailing Address
First Line : 4720 HOEN AVE
Second Line :
City : SANTA ROSA
State : CA
Zip : 95405-7867
Country : US
Telephone Number : 707-527-8222
Fax Number :
Provider Business Practice Location Address
First Line : 4720 HOEN AVE
Second Line :
City : SANTA ROSA
State : CA
Zip : 95405-7867
Country : US
Telephone Number : 707-527-8222
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. BRUCE DAVID GAYNOR
Credential : M.D.
Telephone Number : 707-527-8222
Provider Enumeration Date : 11/17/2006
Last Update Date : 06/17/2008

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