Healthcare Provider Details

I. General information

NPI: 1790116663
Provider Name (Legal Business Name): CARL DEWITTE MEBANE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MYRTLE ST 102
OAKLAND CA
94607-2525
US

IV. Provider business mailing address

362 EUCLID AVE APT 107
OAKLAND CA
94610-3239
US

V. Phone/Fax

Practice location:
  • Phone: 510-839-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: