Healthcare Provider Details

I. General information

NPI: 1306698816
Provider Name (Legal Business Name): ELIASIEH MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 TELEGRAPH AVE STE 210
BERKELEY CA
94705-2049
US

IV. Provider business mailing address

3017 TELEGRAPH AVE STE 210
BERKELEY CA
94705-2049
US

V. Phone/Fax

Practice location:
  • Phone: 510-899-7466
  • Fax: 510-899-6024
Mailing address:
  • Phone: 510-899-7466
  • Fax: 510-899-6024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KASRA ELIASIEH
Title or Position: OWNER
Credential: MD
Phone: 510-899-7466