Provider Demographics
NPI:1164402608
Name:DESELLE, SANDRA (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:DESELLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:BOZICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2909
Mailing Address - Country:US
Mailing Address - Phone:650-947-3937
Mailing Address - Fax:650-947-3935
Practice Address - Street 1:1987 N CARSON ST STE 5
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-1225
Practice Address - Country:US
Practice Address - Phone:775-883-2015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12111-T152W00000X
NV1098152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0121110Medicare ID - Type Unspecified
PAU24498Medicare UPIN