1114066974 NPI number — DR. MAX BARNETT DUNCAN D.O.

Table of content: DR. MAX BARNETT DUNCAN D.O. (NPI 1114066974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114066974 NPI number — DR. MAX BARNETT DUNCAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUNCAN
Provider First Name:
MAX
Provider Middle Name:
BARNETT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114066974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 DISTEL CIR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ALTOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94022-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-521-7788
Provider Business Mailing Address Fax Number:
707-523-1309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3883 AIRWAY DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95403-1670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-521-7755
Provider Business Practice Location Address Fax Number:
707-523-1309
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  128269 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 20A5164 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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