1487601522 NPI number — SPECTRUM EYE PHYSICIANS, A MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487601522 NPI number — SPECTRUM EYE PHYSICIANS, A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM EYE PHYSICIANS, A MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487601522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10300 S DE ANZA BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CUPERTINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95014-3030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-253-3083
Provider Business Mailing Address Fax Number:
408-253-2965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10300 S DE ANZA BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CUPERTINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95014-3030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-253-3083
Provider Business Practice Location Address Fax Number:
408-253-2965
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILHELM
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR/CONTROLLER
Authorized Official Telephone Number:
408-252-7310

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT 13831 TLG , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: SRYGH 97-67584700006 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0103602 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103601 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0103603 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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