Healthcare Provider Details

I. General information

NPI: 1477879609
Provider Name (Legal Business Name): ALLERGY AND IMMUNOLOGY CLINIC OF EAST BAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 WOOLSEY ST STE 314
BERKELEY CA
94705-1973
US

IV. Provider business mailing address

2320 WOOLSEY ST STE 314
BERKELEY CA
94705-1973
US

V. Phone/Fax

Practice location:
  • Phone: 925-270-5119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA83416
License Number StateCA

VIII. Authorized Official

Name: DMITRIY SUKHOV
Title or Position: BUSINESS MANAGER
Credential:
Phone: 925-270-5119