=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073526695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD SPERRAZZO PH D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5190 GOVERNOR DRIVE SUITE 101
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92122-2848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-220-3312
-----------------------------------------------------
Fax | 858-272-1383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3059 STOCKETT WAY
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-220-3312
-----------------------------------------------------
Fax | 858-272-1383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY3232
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------