Provider Demographics
NPI:1588674147
Name:NIENDORF, DANA CHARLES (MD)
Entity Type:Individual
Prefix:MR
First Name:DANA
Middle Name:CHARLES
Last Name:NIENDORF
Suffix:
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 1:1496 PROFESSIONAL DR
Mailing Address - Street 2:STE 603
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-762-0059
Mailing Address - Fax:707-762-8011
Practice Address - Street 1:1496 PROFESSIONAL DR
Practice Address - Street 2:STE 603
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-762-0059
Practice Address - Fax:707-762-8011
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24293208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5233018Medicaid
A42222Medicare UPIN
A42222Medicare ID - Type Unspecified