Provider Demographics
NPI:1477750545
Name:EYEGEN SAN MATEO
Entity Type:Organization
Organization Name:EYEGEN SAN MATEO
Other - Org Name:SITE FOR SORE EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BEZVERKH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-347-1500
Mailing Address - Street 1:115 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4012
Mailing Address - Country:US
Mailing Address - Phone:415-347-1500
Mailing Address - Fax:
Practice Address - Street 1:115 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4012
Practice Address - Country:US
Practice Address - Phone:415-347-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service