Provider Demographics
NPI:1114087764
Name:SACKS, DAVID B (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:SACKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 N TUSTIN AVE
Mailing Address - Street 2:122
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-6505
Mailing Address - Country:US
Mailing Address - Phone:714-542-3961
Mailing Address - Fax:
Practice Address - Street 1:999 N TUSTIN AVE
Practice Address - Street 2:122
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6505
Practice Address - Country:US
Practice Address - Phone:714-542-3961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30335207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A30335Medicaid
CAA30335OtherSTATE LICENCE
CAA30335OtherSTATE LICENCE
CAA26062Medicare UPIN