Provider Demographics
NPI:1205109766
Name:WALNUT CREEK OPTICAL
Entity type:Organization
Organization Name:WALNUT CREEK OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-935-8822
Mailing Address - Street 1:1855 SAN MIGUEL DR
Mailing Address - Street 2:SUITE 28
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5279
Mailing Address - Country:US
Mailing Address - Phone:925-935-8822
Mailing Address - Fax:
Practice Address - Street 1:1988 TICE VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2203
Practice Address - Country:US
Practice Address - Phone:925-925-6650
Practice Address - Fax:925-935-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050143332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0848850001OtherMEDICARE