Provider Demographics
NPI:1396803698
Name:DOYLE PARK FAMILY MEDICINE
Entity type:Organization
Organization Name:DOYLE PARK FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-526-1800
Mailing Address - Street 1:510 DOYLE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4570
Mailing Address - Country:US
Mailing Address - Phone:707-526-1800
Mailing Address - Fax:707-522-1737
Practice Address - Street 1:510 DOYLE PARK DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4570
Practice Address - Country:US
Practice Address - Phone:707-526-1800
Practice Address - Fax:707-522-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068710Medicaid
CAZZZ00875ZMedicare ID - Type Unspecified