Provider Demographics
NPI:1902813322
Name:GIN, BRIAN ALLAN (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALLAN
Last Name:GIN
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 1:39355 CALIFORNIA ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1447
Mailing Address - Country:US
Mailing Address - Phone:510-744-2010
Mailing Address - Fax:510-744-2015
Practice Address - Street 1:39355 CALIFORNIA ST
Practice Address - Street 2:SUITE 103
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1447
Practice Address - Country:US
Practice Address - Phone:510-744-2010
Practice Address - Fax:510-744-2015
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13125T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0022890Medicaid
CAZZZ15747ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
CASD0131252Medicare PIN
CAGR0022890Medicaid