Healthcare Provider Details

I. General information

NPI: 1710972138
Provider Name (Legal Business Name): MIRIAM ALEXANDRA MENZEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRIAM ALEXANDRA GOWON MD

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 03/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 LAWRENCE EXPY DEPT 190
SANTA CLARA CA
95051-5173
US

IV. Provider business mailing address

710 LAWRENCE EXPY DEPT 190
SANTA CLARA CA
95051-5173
US

V. Phone/Fax

Practice location:
  • Phone: 408-851-1161
  • Fax:
Mailing address:
  • Phone: 408-851-1161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG63060
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberG63060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: