Provider Demographics
NPI:1972534253
Name:GAYNOR, BRUCE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DAVID
Last Name:GAYNOR
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 1:4720 HOEN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7867
Mailing Address - Country:US
Mailing Address - Phone:707-527-8222
Mailing Address - Fax:707-527-5318
Practice Address - Street 1:4720 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7867
Practice Address - Country:US
Practice Address - Phone:707-527-8222
Practice Address - Fax:707-527-5318
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG845350174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G845350Medicaid
CA180041368OtherMEDICARE RAILROAD
CA180041368OtherMEDICARE RAILROAD
CAG70889Medicare UPIN
CA00G845350Medicaid