Provider Demographics
NPI:1134188360
Name:GELSTON, WILLIS L (MD)
Entity type:Individual
Prefix:
First Name:WILLIS
Middle Name:L
Last Name:GELSTON
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 1:13851 E 14TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2631
Mailing Address - Country:US
Mailing Address - Phone:510-351-2100
Mailing Address - Fax:510-357-3389
Practice Address - Street 1:13851 E 14TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2631
Practice Address - Country:US
Practice Address - Phone:510-351-2100
Practice Address - Fax:510-357-3389
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32875207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C328750Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER