Provider Demographics
NPI:1073649273
Name:MID-PENINSULA OPTICAL
Entity Type:Organization
Organization Name:MID-PENINSULA OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PAQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-324-4333
Mailing Address - Street 1:883 SANTA CRUZ AVE
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4638
Mailing Address - Country:US
Mailing Address - Phone:650-324-4333
Mailing Address - Fax:650-324-4311
Practice Address - Street 1:883 SANTA CRUZ AVE
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4638
Practice Address - Country:US
Practice Address - Phone:650-324-4333
Practice Address - Fax:650-324-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACL391156FC0801X
CASL0611156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA0391OtherEYEMEDVISIONCARE