Healthcare Provider Details

I. General information

NPI: 1912951385
Provider Name (Legal Business Name): JEFFREY ARTHUR TICE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 DIVISADERO STREET
SAN FRANCISCO CA
94143-0001
US

IV. Provider business mailing address

1635 DIVISADERO STREET, SUITE 625, BOX 1821
SAN FRANCISCO CA
94143-0001
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-7300
  • Fax: 415-353-7901
Mailing address:
  • Phone: 415-476-4102
  • Fax: 415-476-4150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA60233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: