Healthcare Provider Details

I. General information

NPI: 1619409364
Provider Name (Legal Business Name): KALLA ALEXIS GERVASIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 PLEASANT ST STE 1600
CONCORD NH
03301-2588
US

IV. Provider business mailing address

248 PLEASANT ST STE 1600
CONCORD NH
03301-2588
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-2020
  • Fax: 603-228-0248
Mailing address:
  • Phone: 603-224-2020
  • Fax: 603-228-0248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number25190
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: