Provider Demographics
NPI:1528080462
Name:PICO, ELAINE LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:LOUISE
Last Name:PICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20059
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94620-0059
Mailing Address - Country:US
Mailing Address - Phone:510-558-8074
Mailing Address - Fax:510-923-0378
Practice Address - Street 1:3031 TELEGRAPH AVE STE 241
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2053
Practice Address - Country:US
Practice Address - Phone:510-558-8074
Practice Address - Fax:510-923-0378
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG833712081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G833710OtherMEDI-CAL/MEDICAID NUMBER
CA00G833710OtherMEDI-CAL/MEDICAID NUMBER