Provider Demographics
NPI:1891766861
Name:FAUST, ROBERT LOGAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOGAN
Last Name:FAUST
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 1:1210 SONOMA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-544-5093
Mailing Address - Fax:707-528-8444
Practice Address - Street 1:1210 SONOMA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-544-5093
Practice Address - Fax:707-528-8444
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46484207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A464840Medicaid
CAA46484OtherCALIFORNIA MEDICAL LIC #
CAA46484OtherCALIFORNIA MEDICAL LIC #
CA00A464840Medicaid
CAF69903Medicare UPIN