1114034915 NPI number — DIANE V HAVLIR MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114034915 NPI number — DIANE V HAVLIR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAVLIR
Provider First Name:
DIANE
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114034915
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7464
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94120-7464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-206-3103
Provider Business Mailing Address Fax Number:
415-206-3872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 POTRERO AVE
Provider Second Line Business Practice Location Address:
BLDG 80 WARD 84
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94110-3518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-476-4082
Provider Business Practice Location Address Fax Number:
415-502-2992
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G57011 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RI0200X , with the licence number: G57011 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G570110 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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