Provider Demographics
NPI:1427588508
Name:MANUEL, GERDENIO MEDARD
Entity Type:Individual
Prefix:DR
First Name:GERDENIO
Middle Name:MEDARD
Last Name:MANUEL
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 1:2600 TURK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-4347
Mailing Address - Country:US
Mailing Address - Phone:408-476-6874
Mailing Address - Fax:
Practice Address - Street 1:150 GOLDEN GATE AVE FL 2
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3810
Practice Address - Country:US
Practice Address - Phone:415-241-8320
Practice Address - Fax:415-440-7776
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9837103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist