Healthcare Provider Details

I. General information

NPI: 1962275933
Provider Name (Legal Business Name): ISABEL PONTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2526 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-2607
US

IV. Provider business mailing address

1449 GRANT ST
BERKELEY CA
94703-1109
US

V. Phone/Fax

Practice location:
  • Phone: 510-467-0520
  • Fax:
Mailing address:
  • Phone: 512-705-5993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: