Healthcare Provider Details

I. General information

NPI: 1376724955
Provider Name (Legal Business Name): ROBERT PAUL GERVAIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2007
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 W GLENDALE AVE SUITE 103
PHOENIX AZ
85021-8578
US

IV. Provider business mailing address

PO BOX 31270
MESA AZ
85275-1270
US

V. Phone/Fax

Practice location:
  • Phone: 602-995-2000
  • Fax: 602-995-8408
Mailing address:
  • Phone: 602-568-8039
  • Fax: 480-835-7844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number8919
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: