1609809144 NPI number — MEDICAL VISION TECHNOLOGY OPHTHALMOLOGY MEDICAL GROUP INC.

Table of content: (NPI 1609809144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609809144 NPI number — MEDICAL VISION TECHNOLOGY OPHTHALMOLOGY MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL VISION TECHNOLOGY OPHTHALMOLOGY MEDICAL GROUP INC.
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1609809144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 ALHAMBRA BLVD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95816-7050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-731-8040
Provider Business Mailing Address Fax Number:
916-454-4152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 SIERRA GARDENS DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-2942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-782-2111
Provider Business Practice Location Address Fax Number:
916-786-6966
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STONHAM-STEFFENS
Authorized Official First Name:
MAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING/CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
916-731-5955

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207WX0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0042242 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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