Healthcare Provider Details

I. General information

NPI: 1083291934
Provider Name (Legal Business Name): ALICIA LYGIA CALLEJO-BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 POST ST STE 320
SAN FRANCISCO CA
94115-3466
US

IV. Provider business mailing address

550 16TH ST FL 4
SAN FRANCISCO CA
94143-2549
US

V. Phone/Fax

Practice location:
  • Phone: 415-885-7478
  • Fax:
Mailing address:
  • Phone: 415-476-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number197670
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: