Provider Demographics
NPI:1760675656
Name:CORNELIA M PESSOA, MD
Entity Type:Organization
Organization Name:CORNELIA M PESSOA, MD
Other - Org Name:DERMATOLOGY ASSOCIATES OF BERKELEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:MOURA
Authorized Official - Last Name:PESSOA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-486-1700
Mailing Address - Street 1:2500 MILVIA ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2636
Mailing Address - Country:US
Mailing Address - Phone:510-486-1700
Mailing Address - Fax:510-486-1133
Practice Address - Street 1:2500 MILVIA ST
Practice Address - Street 2:SUITE 104
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2636
Practice Address - Country:US
Practice Address - Phone:510-486-1700
Practice Address - Fax:510-486-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60130174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00831ZMedicare PIN