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 1:800 MCCULLOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1625
Mailing Address - Country:US
Mailing Address - Phone:210-226-6169
Mailing Address - Fax:
Practice Address - Street 1:800 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1625
Practice Address - Country:US
Practice Address - Phone:210-226-6169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10203TG152WC0802X, 152WV0400X, 152W00000X
GAOPT002945152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10203TGOtherTEXAS BOARD OF OPTOMETRY