Provider Demographics
NPI:1336219930
Name:VANFOSSAN, DONALD DUANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:DUANE
Last Name:VANFOSSAN
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 1:19200 MOUNTAIN VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:VOLCANO
Mailing Address - State:CA
Mailing Address - Zip Code:95689-9707
Mailing Address - Country:US
Mailing Address - Phone:209-296-3163
Mailing Address - Fax:
Practice Address - Street 1:201 CLINTON RD
Practice Address - Street 2:SUITE 106
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2648
Practice Address - Country:US
Practice Address - Phone:209-223-3021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G5774202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G577420Medicaid
CA00G577420Medicare ID - Type Unspecified
CA00G577420Medicaid