Basic Information
| Provider Information | |||||||||
| NPI: | 1457323446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHEY | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 S FAIRMONT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093342010 | ||||||||
| FaxNumber: | 2093340132 | ||||||||
| Practice Location | |||||||||
| Address1: | 999 S FAIRMONT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093342010 | ||||||||
| FaxNumber: | 2093340132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A78020 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GR0102080 | 05 | CA | MEDICAID |