Provider Demographics
NPI:1598800419
Name:EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP
Entity Type:Organization
Organization Name:EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALLING
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:UDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-823-7628
Mailing Address - Street 1:6574 OAKMONT DR STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-5958
Mailing Address - Country:US
Mailing Address - Phone:707-579-2020
Mailing Address - Fax:707-539-6183
Practice Address - Street 1:6574 OAKMONT DR STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-5958
Practice Address - Country:US
Practice Address - Phone:707-579-2020
Practice Address - Fax:707-539-6183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1247100002Medicare ID - Type Unspecified