Provider Demographics
NPI:1972685972
Name:BIRNBAUM, GARY BENN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:BENN
Last Name:BIRNBAUM
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 1:1580 VALENCIA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4420
Mailing Address - Country:US
Mailing Address - Phone:415-550-4710
Mailing Address - Fax:415-550-6784
Practice Address - Street 1:1580 VALENCIA ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4420
Practice Address - Country:US
Practice Address - Phone:415-550-4710
Practice Address - Fax:415-550-6784
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081800Medicaid
CAA46752Medicare UPIN
CAGR0081800Medicaid