Provider Demographics
NPI:1164615811
Name:GAULT, LANCE GATOR (DO)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:GATOR
Last Name:GAULT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2740 HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6813
Mailing Address - Country:US
Mailing Address - Phone:559-299-2608
Mailing Address - Fax:559-299-1341
Practice Address - Street 1:2740 HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6813
Practice Address - Country:US
Practice Address - Phone:559-299-2608
Practice Address - Fax:559-299-1341
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A10128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine