Healthcare Provider Details

I. General information

NPI: 1326001298
Provider Name (Legal Business Name): MITCHELL ALLEN GEVELBER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

1027 DAISY CT
SUNNYVALE CA
94086-8254
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-5445
  • Fax:
Mailing address:
  • Phone: 408-246-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA70083
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA70083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: