Provider Demographics
NPI:1770645939
Name:REZOWALLI, GARY JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:REZOWALLI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 BERNAL RD STE 140
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1343
Mailing Address - Country:US
Mailing Address - Phone:408-972-6454
Mailing Address - Fax:408-972-6494
Practice Address - Street 1:175 BERNAL RD STE 140
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1343
Practice Address - Country:US
Practice Address - Phone:408-972-6454
Practice Address - Fax:408-972-6494
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical