Provider Demographics
NPI:1184882250
Name:SAN PABLO OPTOMETRIC CENTER, INC.
Entity type:Organization
Organization Name:SAN PABLO OPTOMETRIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:PABLO
Authorized Official - Last Name:ANAYA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-232-3060
Mailing Address - Street 1:14240 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3328
Mailing Address - Country:US
Mailing Address - Phone:510-232-3060
Mailing Address - Fax:510-232-0377
Practice Address - Street 1:14240 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3328
Practice Address - Country:US
Practice Address - Phone:510-232-3060
Practice Address - Fax:510-232-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12274T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0012274Medicaid
CASD0012274Medicaid