Healthcare Provider Details

I. General information

NPI: 1558941872
Provider Name (Legal Business Name): BETHEL ROBA MIESO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 MISSION COLLEGE BLVD
SANTA CLARA CA
95054-1214
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 800-478-8837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number195058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: