Provider Demographics
NPI:1477891794
Name:BODENSTEINER, CLETUS GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:CLETUS
Middle Name:GARY
Last Name:BODENSTEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 HAEHL CREEK CT
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-5755
Mailing Address - Country:US
Mailing Address - Phone:707-459-2708
Mailing Address - Fax:707-459-2804
Practice Address - Street 1:230 HAEHL CREEK CT
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-5755
Practice Address - Country:US
Practice Address - Phone:707-459-2708
Practice Address - Fax:707-459-2804
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24841207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA19135Medicare UPIN