Healthcare Provider Details

I. General information

NPI: 1639110562
Provider Name (Legal Business Name): TESFAYE GEBREKRISTOS GONDEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 S BASCOM AVE PSYCHIATRY DEPARTMENT
SAN JOSE CA
95128-2604
US

IV. Provider business mailing address

10200 MILLER AVE
CUPERTINO CA
95014-3439
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-6100
  • Fax:
Mailing address:
  • Phone: 917-755-1054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA94161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: