Healthcare Provider Details

I. General information

NPI: 1093028714
Provider Name (Legal Business Name): ANNA MRELASHVILI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39650 LIBERTY ST
FREMONT CA
94538-2223
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 408-524-5700
  • Fax: 408-523-3625
Mailing address:
  • Phone: 408-524-5700
  • Fax: 408-523-3625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number38616
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA161653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: