Healthcare Provider Details

I. General information

NPI: 1780601401
Provider Name (Legal Business Name): CRANIOFACIAL MEDICAL ASSOC OF CHRCO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

747 52ND ST
OAKLAND CA
94609-1809
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3150
  • Fax: 510-601-3989
Mailing address:
  • Phone: 510-428-3150
  • Fax: 510-601-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA549520
License Number StateCA

VIII. Authorized Official

Name: ELIO LEAVITT GIZZI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 510-428-3150