Provider Demographics
NPI:1770619926
Name:FATHMAN, C. GARRISON (MD)
Entity type:Individual
Prefix:
First Name:C. GARRISON
Middle Name:
Last Name:FATHMAN
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 1:177 GROVE DR
Mailing Address - Street 2:
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7638
Mailing Address - Country:US
Mailing Address - Phone:650-851-5866
Mailing Address - Fax:650-725-1958
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:CCSR 2225
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-851-5866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33057207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C330570Medicaid
CA00C330570Medicaid
CA00C330570Medicare ID - Type Unspecified