Provider Demographics
NPI:1114377173
Name:PESSOA, CARLOS EDUARDO (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:EDUARDO
Last Name:PESSOA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N HOCKETT ST
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257
Mailing Address - Country:US
Mailing Address - Phone:877-960-3426
Mailing Address - Fax:
Practice Address - Street 1:65 N HOCKETT ST
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002945152WC0802X, 152WX0102X, 152WV0400X, 152WX0102X
CAOPT34675-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT34675-TLGOtherCALIFORNIA BOARD OF OPTOMETRY