Provider Demographics
NPI:1710972138
Name:MENZEL, MIRIAM ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:ALEXANDRA
Last Name:MENZEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MIRIAM
Other - Middle Name:ALEXANDRA
Other - Last Name:GOWON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:710 LAWRENCE EXPY
Mailing Address - Street 2:DEPT 190
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:408-851-1161
Mailing Address - Fax:
Practice Address - Street 1:710 LAWRENCE EXPY
Practice Address - Street 2:DEPT 190
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5173
Practice Address - Country:US
Practice Address - Phone:408-851-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2013-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63060208000000X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G630600Medicaid