Provider Demographics
NPI:1427246453
Name:GARY J PROFFETT, MD, APC
Entity type:Organization
Organization Name:GARY J PROFFETT, MD, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-658-2552
Mailing Address - Street 1:46 CALLE DEL NORTE
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5210
Mailing Address - Country:US
Mailing Address - Phone:805-658-2552
Mailing Address - Fax:
Practice Address - Street 1:1901 SOLAR DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2641
Practice Address - Country:US
Practice Address - Phone:805-658-2552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW4474AMedicare PIN