Provider Demographics
NPI:1467589077
Name:RAYMOND F PEDERSEN O.D. PROFESSIONAL
Entity Type:Organization
Organization Name:RAYMOND F PEDERSEN O.D. PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:F
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-791-5272
Mailing Address - Street 1:38069 MARTHA AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3811
Mailing Address - Country:US
Mailing Address - Phone:510-791-5272
Mailing Address - Fax:510-791-0660
Practice Address - Street 1:38069 MARTHA AVE
Practice Address - Street 2:STE 200
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3811
Practice Address - Country:US
Practice Address - Phone:510-791-5272
Practice Address - Fax:510-791-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8564T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10705Medicare UPIN
CAT10554Medicare UPIN
CA13149TOtherOD LINSENCE