Provider Demographics
NPI:1821092735
Name:TADEWALDT, GORDON (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:TADEWALDT
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:PO BOX 1206
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-1206
Mailing Address - Country:US
Mailing Address - Phone:530-842-7297
Mailing Address - Fax:530-842-9054
Practice Address - Street 1:444 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3450
Practice Address - Country:US
Practice Address - Phone:530-842-7297
Practice Address - Fax:530-842-9054
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78660207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G786600Medicaid
F86068Medicare UPIN
CA00G786600Medicaid