Provider Demographics
NPI:1336164771
Name:HERFINDAHL, GARY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALLEN
Last Name:HERFINDAHL
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 1:908 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2143
Mailing Address - Country:US
Mailing Address - Phone:530-926-3161
Mailing Address - Fax:530-926-0406
Practice Address - Street 1:908 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-3161
Practice Address - Fax:530-926-0406
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51667207PE0004X, 207RC0200X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Not Answered207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G516670OtherBLUE SHIELD OF CALIFORNIA
OR172614Medicaid
CA00G516670Medicaid
SC0662956OtherCHAMPUS
CAG51667OtherBLUE CROSS OF CALIFORNIA
CA00G516670OtherCALIF CHILDREN'S SERVICES
CA00G516670Medicaid
OR172614Medicaid