Provider Demographics
NPI:1700041043
Name:SANDRA DAVIDSON, O.D. INC.
Entity Type:Organization
Organization Name:SANDRA DAVIDSON, O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-784-2420
Mailing Address - Street 1:4515 CENTRAL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2374
Mailing Address - Country:US
Mailing Address - Phone:951-784-2420
Mailing Address - Fax:951-784-4713
Practice Address - Street 1:4515 CENTRAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2374
Practice Address - Country:US
Practice Address - Phone:951-784-2420
Practice Address - Fax:951-784-4713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD009191Medicaid
CASD009191Medicare PIN
CAU383640001Medicare UPIN
CA5644360001Medicare NSC