Provider Demographics
NPI:1962618066
Name:GERVAIS, JULIETTE SELMA (MD)
Entity type:Individual
Prefix:DR
First Name:JULIETTE
Middle Name:SELMA
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 LYNDON B JOHNSON FWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3405
Mailing Address - Country:US
Mailing Address - Phone:800-346-0747
Mailing Address - Fax:
Practice Address - Street 1:500 WINDERLEY PL STE 115
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7406
Practice Address - Country:US
Practice Address - Phone:407-875-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116016721207P00000X
NY255415207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962618066Medicaid
NY03163462Medicaid
VA022607E98Medicare PIN
VA1962618066Medicaid