Provider Demographics
NPI:1043628548
Name:SAPPAL, AMANDEEP (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDEEP
Middle Name:
Last Name:SAPPAL
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 1:1160 MARLOWE CT
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5265
Mailing Address - Country:US
Mailing Address - Phone:707-474-7571
Mailing Address - Fax:
Practice Address - Street 1:1350 TRAVIS BLVD UNIT 1507A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3440
Practice Address - Country:US
Practice Address - Phone:707-421-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15057TLG152W00000X
CA15057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA84-1915375Medicaid