Provider Demographics
NPI:1790778017
Name:CALVERT, BRIAN (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CALVERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3429 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3104
Mailing Address - Country:US
Mailing Address - Phone:707-725-5255
Mailing Address - Fax:707-725-8833
Practice Address - Street 1:3429 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3104
Practice Address - Country:US
Practice Address - Phone:707-725-5255
Practice Address - Fax:707-725-8833
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2008-05-05
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
CA11045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0110451Medicaid
CASD0110450Medicare ID - Type Unspecified
CASD0110451Medicaid
CA5320520001Medicare NSC