Healthcare Provider Details

I. General information

NPI: 1760675656
Provider Name (Legal Business Name): CORNELIA M PESSOA, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MILVIA ST SUITE 104
BERKELEY CA
94704-2636
US

IV. Provider business mailing address

2500 MILVIA ST SUITE 104
BERKELEY CA
94704-2636
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: DR. CORNELIA MOURA PESSOA
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 510-486-1700