Provider Demographics
NPI:1083748248
Name:CENTER FOR DEVELOPING MINDS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CENTER FOR DEVELOPING MINDS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:KORB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-358-1853
Mailing Address - Street 1:22990 SCHULTIES RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95033-8703
Mailing Address - Country:US
Mailing Address - Phone:408-358-1853
Mailing Address - Fax:
Practice Address - Street 1:15951 LOS GATOS BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3428
Practice Address - Country:US
Practice Address - Phone:408-358-1853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA626862080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty