Provider Demographics
NPI:1225028236
Name:VISUAL EDGE OPTOMERTIC GROUP
Entity Type:Organization
Organization Name:VISUAL EDGE OPTOMERTIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOVACH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-842-2020
Mailing Address - Street 1:8050 SANTA TERESA BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3862
Mailing Address - Country:US
Mailing Address - Phone:408-842-2020
Mailing Address - Fax:408-842-0312
Practice Address - Street 1:8050 SANTA TERESA BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3862
Practice Address - Country:US
Practice Address - Phone:408-842-2020
Practice Address - Fax:408-842-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8766T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004630Medicaid
CASD0087660Medicaid
1225028236OtherNPI NUMBER
1225028236OtherNPI NUMBER
4113270001Medicare NSC