Provider Demographics
NPI:1164427282
Name:DAVIDSON, SANDRA M (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:M
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:M
Other - Last Name:AKAMINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:4515 CENTRAL AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2374
Mailing Address - Country:US
Mailing Address - Phone:951-784-2420
Mailing Address - Fax:951-784-4713
Practice Address - Street 1:4515 CENTRAL AVE
Practice Address - Street 2:STE 101
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2374
Practice Address - Country:US
Practice Address - Phone:951-784-2420
Practice Address - Fax:951-784-4713
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9191TPL152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD009191Medicaid
CA5644360001Medicare NSC
CASD009191Medicaid
CASD009191Medicaid