Healthcare Provider Details

I. General information

NPI: 1427506955
Provider Name (Legal Business Name): DEXTER LOUIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 10/18/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 WILLOW RD MAIL STOP 170A/MPD
MENLO PARK CA
94025-2539
US

IV. Provider business mailing address

795 WILLOW RD MAIL STOP 170A/MPD
MENLO PARK CA
94025-2539
US

V. Phone/Fax

Practice location:
  • Phone: 650-614-9997
  • Fax: 650-617-2687
Mailing address:
  • Phone: 650-614-9997
  • Fax: 650-617-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number67556
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA157092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: