1477915148 NPI number — DR. TESSA BLAIR JOHUNG MD, PHD

Table of content: DR. TESSA BLAIR JOHUNG MD, PHD (NPI 1477915148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477915148 NPI number — DR. TESSA BLAIR JOHUNG MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHUNG
Provider First Name:
TESSA
Provider Middle Name:
BLAIR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
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:
1477915148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 PARNASSUS AVE # M-798
Provider Second Line Business Mailing Address:
BOX 0114
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94143-2204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 PARNASSUS AVE # M-798
Provider Second Line Business Practice Location Address:
BOX 0114
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94143-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-476-3891
Provider Business Practice Location Address Fax Number:
415-476-3428
Provider Enumeration Date:
03/22/2016

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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