Provider Demographics
NPI:1508871187
Name:DECLERCQ, SONJA S (MD)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:S
Last Name:DECLERCQ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 OAK GROVE AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025
Mailing Address - Country:US
Mailing Address - Phone:650-325-3937
Mailing Address - Fax:
Practice Address - Street 1:724 OAK GROVE AVE
Practice Address - Street 2:STE 130
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025
Practice Address - Country:US
Practice Address - Phone:650-325-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29789207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A25878Medicare UPIN
CA00A297890Medicare ID - Type Unspecified