Provider Demographics
NPI:1134127939
Name:MAES, GARY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LYNN
Last Name:MAES
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-525-6485
Mailing Address - Fax:707-262-5844
Practice Address - Street 1:5108 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-262-1840
Practice Address - Fax:707-262-5844
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2012-02-08
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Provider Licenses
StateLicense IDTaxonomies
CAG37389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA080048856OtherRAILROAD MEDICARE
CA00G373890OtherBLUE SHIELD OF CALIFORNIA
CA00G373890Medicaid
CA080048856OtherRAILROAD MEDICARE
CA00G373890Medicaid