Healthcare Provider Details

I. General information

NPI: 1659445344
Provider Name (Legal Business Name): EAST OAKLAND PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 FOOTHILL BLVD
OAKLAND CA
94601
US

IV. Provider business mailing address

5461 FOOTHILL BLVD EAST OAKLAND PEDIATRICS INC
OAKLAND CA
94601
US

V. Phone/Fax

Practice location:
  • Phone: 510-532-0918
  • Fax: 510-532-0956
Mailing address:
  • Phone: 510-532-0918
  • Fax: 510-532-0956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROL ELIZABETH GLANN
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 510-532-0918