Provider Demographics
NPI:1235115718
Name:SANDERS, TIMOTHY LEWIS (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEWIS
Last Name:SANDERS
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 1:491 30TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3052
Mailing Address - Country:US
Mailing Address - Phone:510-444-0603
Mailing Address - Fax:510-444-6046
Practice Address - Street 1:491 30TH ST
Practice Address - Street 2:STE 101
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3052
Practice Address - Country:US
Practice Address - Phone:510-444-0603
Practice Address - Fax:510-444-6046
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5762T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0057620Medicaid
CASD0057621Medicare ID - Type Unspecified
CASD0057620Medicare ID - Type Unspecified
CASD0057620Medicaid