Healthcare Provider Details

I. General information

NPI: 1134188360
Provider Name (Legal Business Name): WILLIS L GELSTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13851 E 14TH ST SUITE 102
SAN LEANDRO CA
94578-2631
US

IV. Provider business mailing address

13851 E 14TH ST SUITE 102
SAN LEANDRO CA
94578-2631
US

V. Phone/Fax

Practice location:
  • Phone: 510-351-2100
  • Fax: 510-357-3389
Mailing address:
  • Phone: 510-351-2100
  • Fax: 510-357-3389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberC32875
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: