Provider Demographics
NPI:1437165107
Name:BAVUSO, FRANK R (MD)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:R
Last Name:BAVUSO
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:PO BOX 1676
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95473
Mailing Address - Country:US
Mailing Address - Phone:707-829-5883
Mailing Address - Fax:707-829-5895
Practice Address - Street 1:400 MORRIS STREET
Practice Address - Street 2:SUITE H
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:707-829-5883
Practice Address - Fax:707-829-5895
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15463207ZP0101X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A39534Medicare UPIN
00G154630Medicare ID - Type Unspecified