Provider Demographics
NPI:1720011158
Name:MEDICAL VISION TECHNOLOGY OPHTHALMOLOGY GROUP, INC
Entity Type:Organization
Organization Name:MEDICAL VISION TECHNOLOGY OPHTHALMOLOGY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-731-5955
Mailing Address - Street 1:1700 ALHAMBRA BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-7050
Mailing Address - Country:US
Mailing Address - Phone:916-731-8040
Mailing Address - Fax:916-454-4152
Practice Address - Street 1:120A W COURT ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2901
Practice Address - Country:US
Practice Address - Phone:530-668-6000
Practice Address - Fax:530-668-9560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0042243Medicaid
CAGR0042243Medicaid