Provider Demographics
NPI:1376894782
Name:SPECTRUM EYE PHYSICIANS, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SPECTRUM EYE PHYSICIANS, A MEDICAL CORPORATION
Other - Org Name:SPECTRUM EYE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:COE
Authorized Official - Phone:408-252-7310
Mailing Address - Street 1:10300 S DE ANZA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3030
Mailing Address - Country:US
Mailing Address - Phone:408-253-3083
Mailing Address - Fax:408-253-2965
Practice Address - Street 1:431 MONTEREY AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5319
Practice Address - Country:US
Practice Address - Phone:408-354-9510
Practice Address - Fax:408-395-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13829 TLG152W00000X
CAG26839207W00000X
CAA69913207W00000X
CA97-675847 00002 GH332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty