Provider Demographics
NPI:1619409364
Name:GERVASIO, KALLA ALEXIS (MD)
Entity type:Individual
Prefix:DR
First Name:KALLA
Middle Name:ALEXIS
Last Name:GERVASIO
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 1:248 PLEASANT ST STE 1600
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2588
Mailing Address - Country:US
Mailing Address - Phone:603-224-2020
Mailing Address - Fax:603-228-0248
Practice Address - Street 1:248 PLEASANT ST STE 1600
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2588
Practice Address - Country:US
Practice Address - Phone:603-224-2020
Practice Address - Fax:603-228-0248
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH25190207WX0200X
PAMD473223207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200109577Medicaid