Healthcare Provider Details

I. General information

NPI: 1255807152
Provider Name (Legal Business Name): GARY BIRNBAUM MD PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 VISTA DEL SOL
MILL VALLEY CA
94941-4920
US

IV. Provider business mailing address

97 VISTA DEL SOL
MILL VALLEY CA
94941-4920
US

V. Phone/Fax

Practice location:
  • Phone: 415-350-0639
  • Fax: 415-366-2882
Mailing address:
  • Phone: 415-350-0639
  • Fax: 415-366-2882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID G HARNDEN
Title or Position: ADMINISTRATIVE MANAGER
Credential:
Phone: 415-648-2021