Provider Demographics
NPI:1114179009
Name:CAMPBELL OPTOMETRIC GROUP
Entity Type:Organization
Organization Name:CAMPBELL OPTOMETRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANANGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-378-4661
Mailing Address - Street 1:621 E CAMPBELL AVE STE 11B
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2136
Mailing Address - Country:US
Mailing Address - Phone:408-378-4661
Mailing Address - Fax:408-378-6160
Practice Address - Street 1:621 E CAMPBELL AVE STE 11B
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2136
Practice Address - Country:US
Practice Address - Phone:408-378-4661
Practice Address - Fax:408-378-6160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5902T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49157YMedicaid
CAU27788Medicare UPIN
CAT10163Medicare UPIN
CA0405480001Medicare PIN
CAYYY49157YMedicaid