MEDICARE: DR. JASON CUNNINGHAM DO

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	207Q00000X	Family Medicine Physician	20A8284	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	ZZZ23666Z	OTHER	CA	BLUE SHIELD PIN
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811990237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON CUNNINGHAM DO

Provider Business Mailing Address
First Line	:	PO BOX 1449
Second Line	:
City	:	GUERNEVILLE
State	:	CA
Zip	:	95446-1449
Country	:	US
Telephone Number	:	707-869-5977
Fax Number	:	707-869-5983

Provider Business Practice Location Address
First Line	:	6800 PALM AVE
Second Line	:	SUITE C
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-4269
Country	:	US
Telephone Number	:	707-824-9999
Fax Number	:	707-824-2853

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	06/25/2015

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