Healthcare Provider Details

I. General information

NPI: 1689757635
Provider Name (Legal Business Name): CORNELIA MOURA PESSOA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 WOOLSEY ST SUITE 202
BERKELEY CA
94705-1973
US

IV. Provider business mailing address

2320 WOOLSEY ST SUITE 202
BERKELEY CA
94705-1973
US

V. Phone/Fax

Practice location:
  • Phone: 510-486-1700
  • Fax: 510-486-1133
Mailing address:
  • Phone: 510-486-1700
  • Fax: 510-486-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG60130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: