Provider Demographics
NPI:1184649196
Name:TAM, DAVID WALTER (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WALTER
Last Name:TAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 SAN PABLO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2077
Mailing Address - Country:US
Mailing Address - Phone:510-964-7816
Mailing Address - Fax:510-964-7831
Practice Address - Street 1:1660 SAN PABLO AVE
Practice Address - Street 2:STE 200
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2077
Practice Address - Country:US
Practice Address - Phone:510-964-7816
Practice Address - Fax:510-964-7831
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7588TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0075880Medicaid
CA0511730001Medicare NSC
CAT10563Medicare UPIN
CASD0075880Medicare PIN
CASD0075880Medicaid