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General NPI Number Information
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NPI Number | 1619409364
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Entity Type | Individual
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Provider Name | KALLA ALEXIS GERVASIO MD
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Gender | Female
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Dates
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Enumeration Date | 03/31/2017
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Last Update Date | 07/09/2024
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Provider Practice Location Address
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Address Line | 248 PLEASANT ST STE 1600
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City | CONCORD
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State | NH
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Zip | 03301-2588
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Country | US
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Telephone | 603-224-2020
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Fax | 603-228-0248
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Provider Business Mailing Address
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Address Line | 248 PLEASANT ST STE 1600
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City | CONCORD
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State | NH
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Zip | 03301-2588
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Country | US
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Telephone | 603-224-2020
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Fax | 603-228-0248
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207WX0200X
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Taxonomy Name | Ophthalmic Plastic and Reconstructive Surgery Physician
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License Number | 25190
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License Number State | NH
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