Provider Demographics
NPI:1093036717
Name:FEDOROFF, GARY
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:FEDOROFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 CARLOS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2005
Mailing Address - Country:US
Mailing Address - Phone:415-755-2310
Mailing Address - Fax:415-755-2210
Practice Address - Street 1:171 CARLOS DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2005
Practice Address - Country:US
Practice Address - Phone:415-755-2310
Practice Address - Fax:415-755-2210
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)