Healthcare Provider Details

I. General information

NPI: 1114377173
Provider Name (Legal Business Name): CARLOS EDUARDO PESSOA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MCCULLOUGH AVE
SAN ANTONIO TX
78215-1625
US

IV. Provider business mailing address

800 MCCULLOUGH AVE
SAN ANTONIO TX
78215-1625
US

V. Phone/Fax

Practice location:
  • Phone: 210-226-6169
  • Fax:
Mailing address:
  • Phone: 210-226-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number10203TG
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number10203TG
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10203TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: