Provider Demographics
NPI:1184610941
Name:LOS ALTOS OPTOMETRIC GROUP, INC.
Entity type:Organization
Organization Name:LOS ALTOS OPTOMETRIC GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PESNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:650-948-3700
Mailing Address - Street 1:133 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2745
Mailing Address - Country:US
Mailing Address - Phone:650-948-3700
Mailing Address - Fax:650-941-9980
Practice Address - Street 1:133 2ND ST
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-2745
Practice Address - Country:US
Practice Address - Phone:650-948-3700
Practice Address - Fax:650-941-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05315T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1292250001Medicare NSC
CAT09945Medicare UPIN
CASD0053150Medicare ID - Type Unspecified