Provider Demographics
NPI:1619180171
Name:FREMONT OPTOMETRIC VISION CARE CENTER
Entity Type:Organization
Organization Name:FREMONT OPTOMETRIC VISION CARE CENTER
Other - Org Name:FREMONT OPTOMETRIC VISION CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:LOWE
Authorized Official - Last Name:HAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-792-9900
Mailing Address - Street 1:3935 BEACON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1458
Mailing Address - Country:US
Mailing Address - Phone:510-792-9900
Mailing Address - Fax:510-792-9906
Practice Address - Street 1:3935 BEACON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1458
Practice Address - Country:US
Practice Address - Phone:510-792-9900
Practice Address - Fax:510-792-9906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0058710Medicaid
CASD0058710Medicaid
CAT10150Medicare UPIN
CAZZZ250732ZMedicare PIN
CAT10150Medicare PIN