Provider Demographics
NPI:1194742106
Name:INCAUDO, GARY A (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:INCAUDO
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 1:145 MISSION RANCH BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2175
Mailing Address - Country:US
Mailing Address - Phone:530-896-2200
Mailing Address - Fax:530-896-2209
Practice Address - Street 1:145 MISSION RANCH BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2175
Practice Address - Country:US
Practice Address - Phone:530-896-2200
Practice Address - Fax:530-896-2209
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27753207K00000X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G277530Medicaid
CA00G277530Medicare PIN
CA00G277530Medicaid
AQ674ZMedicare PIN
00G277531Medicare PIN