Provider Demographics
NPI:1447789623
Name:SAN JOSE EYE CARE OPTOMETRY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SAN JOSE EYE CARE OPTOMETRY PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:THAO
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-259-1818
Mailing Address - Street 1:301 N. JACKSON AVE. #1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95133
Mailing Address - Country:US
Mailing Address - Phone:408-259-1818
Mailing Address - Fax:408-259-1871
Practice Address - Street 1:301 N. JACKSON AVE #1
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95133
Practice Address - Country:US
Practice Address - Phone:408-259-1818
Practice Address - Fax:408-259-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11478T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD011478Medicaid