Healthcare Provider Details

I. General information

NPI: 1346557139
Provider Name (Legal Business Name): MICHAEL DEFTOS M.D.,PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 39TH AVE
SAN FRANCISCO CA
94116-2154
US

IV. Provider business mailing address

2455 39TH AVE
SAN FRANCISCO CA
94116-2154
US

V. Phone/Fax

Practice location:
  • Phone: 415-504-7422
  • Fax:
Mailing address:
  • Phone: 415-504-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA98387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: