Provider Demographics
NPI:1508881459
Name:GAULTER, CONSTANCE E (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:E
Last Name:GAULTER
Suffix:
Gender:F
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 459001
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9101
Mailing Address - Country:US
Mailing Address - Phone:530-272-9770
Mailing Address - Fax:530-272-9796
Practice Address - Street 1:140 LITTON DR STE 110
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5078
Practice Address - Country:US
Practice Address - Phone:530-272-9770
Practice Address - Fax:530-272-9796
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G557651Medicare ID - Type UnspecifiedPROVIDER ID NUMBER