Provider Demographics
NPI:1356369508
Name:DUCKHAM, DEWEY JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:DEWEY
Middle Name:JEFFREY
Last Name:DUCKHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:DEWEY
Other - Last Name:DUCKHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15251 NATIONAL AVE.
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032
Mailing Address - Country:US
Mailing Address - Phone:408-358-3835
Mailing Address - Fax:408-358-2765
Practice Address - Street 1:15251 NATIONAL AVE. SUITE 108
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032
Practice Address - Country:US
Practice Address - Phone:408-358-3835
Practice Address - Fax:408-358-2765
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA036604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28138Medicare UPIN