Provider Demographics
NPI:1598752909
Name:SEVERIN, KATHERINE M (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:M
Last Name:SEVERIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 HILBORN RD STE 500
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7997
Mailing Address - Country:US
Mailing Address - Phone:707-426-2020
Mailing Address - Fax:
Practice Address - Street 1:3700 HILBORN RD STE 500
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-7997
Practice Address - Country:US
Practice Address - Phone:707-426-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP8122T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680346182OtherBLUECROSS
CASD0081220OtherBLUESHIELD
CA5666727Medicaid
CASD0081220Medicare PIN
CASD0081220OtherBLUESHIELD
CA0967240001Medicare NSC
CA680346182OtherBLUECROSS