Healthcare Provider Details

I. General information

NPI: 1205978806
Provider Name (Legal Business Name): CARL ANDREW BERTELSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 SAMARITAN DR
SAN JOSE CA
95124-3912
US

IV. Provider business mailing address

2450 SAMARITAN DR
SAN JOSE CA
95124-3912
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-1855
  • Fax: 408-356-4183
Mailing address:
  • Phone: 408-358-1855
  • Fax: 408-356-4183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG44277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: