Provider Demographics
NPI:1629146147
Name:NOLA, GAETON THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GAETON
Middle Name:THOMAS
Last Name:NOLA
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 1:15047 LOS GATOS BLVD
Mailing Address - Street 2:STE. 150
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2054
Mailing Address - Country:US
Mailing Address - Phone:408-356-2244
Mailing Address - Fax:408-395-4849
Practice Address - Street 1:15047 LOS GATOS BLVD
Practice Address - Street 2:STE. 150
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2054
Practice Address - Country:US
Practice Address - Phone:408-356-2244
Practice Address - Fax:408-395-4849
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-04-05
Deactivation Date:2007-03-13
Deactivation Code:
Reactivation Date:2008-04-04
Provider Licenses
StateLicense IDTaxonomies
CAG30729208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A44526Medicare UPIN
00G307290Medicare ID - Type Unspecified