Provider Demographics
NPI:1568583201
Name:MAIN, GERALD DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:DENNIS
Last Name:MAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GERRY
Other - Middle Name:DENNIS
Other - Last Name:MAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1462
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA
Mailing Address - State:CA
Mailing Address - Zip Code:93428-1462
Mailing Address - Country:US
Mailing Address - Phone:805-927-3713
Mailing Address - Fax:
Practice Address - Street 1:602 EXETER LANE
Practice Address - Street 2:
Practice Address - City:CAMBRIA
Practice Address - State:CA
Practice Address - Zip Code:93428
Practice Address - Country:US
Practice Address - Phone:805-927-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24331207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology