Provider Demographics
NPI:1568434272
Name:SOMDAHL, JERALD GARNER (DPM)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:GARNER
Last Name:SOMDAHL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-2803
Mailing Address - Country:US
Mailing Address - Phone:805-933-1313
Mailing Address - Fax:805-933-9866
Practice Address - Street 1:134 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-2803
Practice Address - Country:US
Practice Address - Phone:805-933-1313
Practice Address - Fax:805-933-9866
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3590213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E35901Medicaid
CA000E35901Medicaid
CAE3590CMedicare ID - Type Unspecified
CAE3590AMedicare PIN
CAE3590AMedicare ID - Type Unspecified