Provider Demographics
NPI: | 1033247457 |
---|---|
Name: | MCCOY, MAUREEN (OD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MAUREEN |
Middle Name: | |
Last Name: | MCCOY |
Suffix: | |
Gender: | F |
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: | 33 CALEDONIA ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SAUSALITO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 94965-2116 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 415-331-0121 |
Mailing Address - Fax: | 415-331-0149 |
Practice Address - Street 1: | 33 CALEDONIA ST |
Practice Address - Street 2: | |
Practice Address - City: | SAUSALITO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 94965-2116 |
Practice Address - Country: | US |
Practice Address - Phone: | 415-331-0121 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-02-28 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 12409T | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 90-0160128 | Other | FEDERAL TAX ID |
CA | 90-0160128 | Other | FEDERAL TAX ID |
CA | 90-0160128 | Other | FEDERAL TAX ID |
CA | MM1000392 | Other | DEA NUMBER |
CA | SDO24090 | Medicare ID - Type Unspecified | USE ON HFCA FORM |
CA | 5518290001 | Medicare NSC |