Provider Demographics
NPI:1548334006
Name:BRUCE D. GAYNOR, M.D., MEDICAL CORPORATION
Entity type:Organization
Organization Name:BRUCE D. GAYNOR, M.D., MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-527-8222
Mailing Address - Street 1:4720 HOEN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7867
Mailing Address - Country:US
Mailing Address - Phone:707-527-8222
Mailing Address - Fax:
Practice Address - Street 1:4720 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7867
Practice Address - Country:US
Practice Address - Phone:707-527-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
CAG84535156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA180041368OtherMEDICARE RAILROAD
CA00G845350Medicaid
CA3899760001Medicare NSC
CA180041368OtherMEDICARE RAILROAD
CA00G845350Medicare PIN