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4633 Old Ironsides Dr Ste 304 Santa Clara CA 95054-1846 | |
| (323) 205-7088 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 4633 Old Ironsides Dr Ste 304, Santa Clara, California |
| Authorized Official Name and Position | Gabriel Diop (AUTHORIZED AGENT) |
| Authorized Official Contact | 3232057088 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 746877 Atlanta GA 30374-6877 Ph: (323) 205-7088 | 4633 Old Ironsides Dr Ste 304 Santa Clara CA 95054-1846 Ph: (323) 205-7088 |
| NPI Number | 1972138238 |
|---|---|
| Provider Enumeration Date | 03/06/2020 |
| Last Update Date | 01/09/2025 |
| Certification Date | 01/09/2025 |
| Medicare PECOS PAC ID | 9537534177 |
|---|---|
| Medicare Enrollment ID | O20230412001370 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972138238 | NPI | - | NPPES |
| Provider Name | Mark Leon Willenbring |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1003930124 PECOS PAC ID: 1850302597 Enrollment ID: I20240919001970 |
| Provider Name | Curran Mark Commerford |
|---|---|
| Provider Type | Practitioner - Psychologist Billing Independently |
| Provider Identifiers | NPI Number: 1528375847 PECOS PAC ID: 3577094283 Enrollment ID: I20241007000000 |
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