Provider Demographics
NPI:1336492685
Name:SOSA, EILLEN CAROLINA (SLD)
Entity Type:Individual
Prefix:
First Name:EILLEN
Middle Name:CAROLINA
Last Name:SOSA
Suffix:
Gender:F
Credentials:SLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 FRUITVALE AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2413
Mailing Address - Country:US
Mailing Address - Phone:510-731-6976
Mailing Address - Fax:510-698-8744
Practice Address - Street 1:1940 FRUITVALE AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2413
Practice Address - Country:US
Practice Address - Phone:510-731-6976
Practice Address - Fax:510-698-8744
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7662156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician