Provider Demographics
NPI:1225120686
Name:SAKS, GARY RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RICHARD
Last Name:SAKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17003 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-1224
Mailing Address - Country:US
Mailing Address - Phone:858-485-6853
Mailing Address - Fax:858-485-8311
Practice Address - Street 1:17631 W BERNARDO DR STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1135
Practice Address - Country:US
Practice Address - Phone:858-487-7900
Practice Address - Fax:858-487-1896
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5592 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055920Medicaid
CAOP5592Medicare ID - Type Unspecified
CASD0055920Medicaid