Healthcare Provider Details

I. General information

NPI: 1922272525
Provider Name (Legal Business Name): ELAINE L PICO, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 INTERNATIONAL BLVD ROOM RC121
OAKLAND CA
94601-1543
US

IV. Provider business mailing address

PO BOX 20059
OAKLAND CA
94620-0059
US

V. Phone/Fax

Practice location:
  • Phone: 510-558-8074
  • Fax:
Mailing address:
  • Phone: 510-558-8074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberG83371
License Number StateCA

VIII. Authorized Official

Name: ELAINE L PICO
Title or Position: OWNER
Credential: M.D.
Phone: 510-558-8074