Healthcare Provider Details

I. General information

NPI: 1073045381
Provider Name (Legal Business Name): JUDAH JOSHUA MIRVISH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 ELLIS ST FL 5
SAN FRANCISCO CA
94109-7714
US

IV. Provider business mailing address

2120 FUNSTON AVE
SAN FRANCISCO CA
94116-1903
US

V. Phone/Fax

Practice location:
  • Phone: 415-833-2292
  • Fax: 702-529-4030
Mailing address:
  • Phone: 415-710-2179
  • Fax: 702-529-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberD0086815
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA178097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: