Provider Demographics
NPI:1699723379
Name:DAVERN, TIMOTHY J (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:DAVERN
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:415-600-1000
Mailing Address - Fax:415-558-7051
Practice Address - Street 1:1100 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6978
Practice Address - Country:US
Practice Address - Phone:415-600-1000
Practice Address - Fax:415-558-7051
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79521207R00000X, 207RG0100X
CA27766207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0G7952100Medicaid
CAG79521OtherSTATE MEDICAL LICENSE
CA0G7952100Medicaid