Provider Demographics
NPI:1386662716
Name:REGENTS OF THE UNIV OF CA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIV OF CA
Other - Org Name:REGENTS UCDPBG OPTOMETRY
Other - Org Type:Other Name
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-734-1166
Mailing Address - Street 1:4900 BROADWAY
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820
Mailing Address - Country:US
Mailing Address - Phone:916-734-9200
Mailing Address - Fax:916-734-9336
Practice Address - Street 1:4860 Y ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-734-6967
Practice Address - Fax:916-452-9327
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIV OF CA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD003030Medicaid
CAZZZP3420ZMedicare ID - Type Unspecified