Healthcare Provider Details

I. General information

NPI: 1790883080
Provider Name (Legal Business Name): PAUL T. KEFALIDES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 MONTGOMERY DR STE C
SANTA ROSA CA
95404-6615
US

IV. Provider business mailing address

98 MONTGOMERY DR STE C
SANTA ROSA CA
95404-6615
US

V. Phone/Fax

Practice location:
  • Phone: 707-591-0619
  • Fax: 707-591-0617
Mailing address:
  • Phone: 707-591-0619
  • Fax: 707-591-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA75614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: