Provider Demographics
NPI:1811990237
Name:CUNNINGHAM, JASON (DO)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-869-5977
Mailing Address - Fax:707-869-5983
Practice Address - Street 1:6800 PALM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4269
Practice Address - Country:US
Practice Address - Phone:707-824-9999
Practice Address - Fax:707-824-2853
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8284207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX82840Medicaid
CA1598768962Medicaid
CAZZZ23666ZOtherBLUE SHIELD PIN
CA1356344758Medicaid
CA1538334065Medicaid
237310613OtherTIN
CA551803Medicare Oscar/Certification
CAZZZ23666ZOtherBLUE SHIELD PIN
237310613OtherTIN
CA1538334065Medicaid
CA551803Medicare Oscar/Certification