Provider Demographics
NPI:1043386832
Name:MONTALVO, ANDY RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:RICHARD
Last Name:MONTALVO
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 1:1351 ISABELLE CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-7517
Mailing Address - Country:US
Mailing Address - Phone:650-992-7003
Mailing Address - Fax:
Practice Address - Street 1:1955 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2205
Practice Address - Country:US
Practice Address - Phone:510-832-0251
Practice Address - Fax:510-832-0252
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10718T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0107180Medicaid