Provider Demographics
NPI:1073045381
Name:MIRVISH, JUDAH JOSHUA
Entity Type:Individual
Prefix:
First Name:JUDAH
Middle Name:JOSHUA
Last Name:MIRVISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 FUNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1903
Mailing Address - Country:US
Mailing Address - Phone:415-710-2179
Mailing Address - Fax:702-529-4030
Practice Address - Street 1:939 ELLIS ST FL 5
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-7714
Practice Address - Country:US
Practice Address - Phone:415-833-2292
Practice Address - Fax:702-529-4030
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0086815390200000X
CAA1780972084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program