Healthcare Provider Details

I. General information

NPI: 1699723379
Provider Name (Legal Business Name): TIMOTHY J. DAVERN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VAN NESS AVE
SAN FRANCISCO CA
94109-6978
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-1000
  • Fax: 415-558-7051
Mailing address:
  • Phone: 415-600-1000
  • Fax: 415-558-7051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG79521
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG79521
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number27766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: