Provider Demographics
NPI:1649216672
Name:SHELDON M. GOLDEN OD, OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:SHELDON M. GOLDEN OD, OPTOMETRIC CORPORATION
Other - Org Name:GOLDEN OPTOMETRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-962-5868
Mailing Address - Street 1:1026 W WEST COVINA PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2810
Mailing Address - Country:US
Mailing Address - Phone:626-962-5868
Mailing Address - Fax:626-856-0570
Practice Address - Street 1:1026 W WEST COVINA PKWY STE B
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2810
Practice Address - Country:US
Practice Address - Phone:626-962-5868
Practice Address - Fax:626-856-0570
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELDON M. GOLDEN OD,OPTOMETRIC CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8726152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001880Medicaid
CA1649216672Medicaid
CAWY6068Medicare PIN