Provider Demographics
NPI:1114948866
Name:SILVER OD PC & TAKETA OD PC A PARTNERSHIP OF OPT CORP
Entity Type:Organization
Organization Name:SILVER OD PC & TAKETA OD PC A PARTNERSHIP OF OPT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SILVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-829-0055
Mailing Address - Street 1:2901 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4901
Mailing Address - Country:US
Mailing Address - Phone:310-829-0055
Mailing Address - Fax:310-453-2971
Practice Address - Street 1:2901 WILSHIRE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4901
Practice Address - Country:US
Practice Address - Phone:310-829-0055
Practice Address - Fax:310-453-2971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6805TPA152W00000X
CAOPT9103TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWY400Medicare PIN
CA0283540001Medicare NSC