Provider Demographics
NPI:1326105313
Name:PACE, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WEST THIRD ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-0100
Mailing Address - Country:US
Mailing Address - Phone:707-894-4229
Mailing Address - Fax:
Practice Address - Street 1:1381 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448
Practice Address - Country:US
Practice Address - Phone:707-433-5494
Practice Address - Fax:707-431-8649
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG21155Medicare UPIN