Provider Demographics
NPI:1457323446
Name:FAHEY, GORDON THOMAS JR (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:THOMAS
Last Name:FAHEY
Suffix:JR
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 1:999 S FAIRMONT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5100
Mailing Address - Country:US
Mailing Address - Phone:209-334-2010
Mailing Address - Fax:209-334-0132
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5100
Practice Address - Country:US
Practice Address - Phone:209-334-2010
Practice Address - Fax:209-334-0132
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102080Medicaid
CA00A780200Medicare PIN
CAGR0102080Medicaid