Provider Demographics
NPI:1437797271
Name:PONTECORVO, ALICIA (RD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:PONTECORVO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MONTECILLO RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3308
Mailing Address - Country:US
Mailing Address - Phone:510-517-5547
Mailing Address - Fax:
Practice Address - Street 1:99 MONTECILLO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3308
Practice Address - Country:US
Practice Address - Phone:415-444-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1076109133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered