Healthcare Provider Details

I. General information

NPI: 1457857609
Provider Name (Legal Business Name): EVAN JAMES LUXENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MONTECILLO RD
SAN RAFAEL CA
94903-3308
US

IV. Provider business mailing address

99 MONTECILLO RD. MEDICAL OFFICE BUILDING TWO 1ST FLOOR
SAN RAFAEL CA
94903-3308
US

V. Phone/Fax

Practice location:
  • Phone: 415-444-2905
  • Fax:
Mailing address:
  • Phone: 415-444-2905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD61278845
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number187130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: