Provider Demographics
NPI:1326001298
Name:GEVELBER, MITCHELL ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ALLEN
Last Name:GEVELBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 DAISY CT
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-8254
Mailing Address - Country:US
Mailing Address - Phone:408-246-2557
Mailing Address - Fax:
Practice Address - Street 1:751 S BASCOM AVE
Practice Address - Street 2:PEDIATRICS DEPARTMENT
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2604
Practice Address - Country:US
Practice Address - Phone:408-885-5445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70083208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A700830Medicaid
CA00A700830Medicaid
CA00A700830Medicare ID - Type Unspecified