Provider Demographics
NPI:1255406690
Name:LARRY R FABIAN & JEFFREY M FANELLI PTRS WESTSIDE FAMILY VISION CENTER
Entity type:Organization
Organization Name:LARRY R FABIAN & JEFFREY M FANELLI PTRS WESTSIDE FAMILY VISION CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-370-7303
Mailing Address - Street 1:1817 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5624
Mailing Address - Country:US
Mailing Address - Phone:408-264-1555
Mailing Address - Fax:408-264-1562
Practice Address - Street 1:18780 COX AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-4109
Practice Address - Country:US
Practice Address - Phone:408-370-7303
Practice Address - Fax:408-370-7405
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LARRY R FABIAN & JEFFREY M FANELLI PTRS WESTSIDE FAMILY VISION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABOL2584152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081680Medicare ID - Type UnspecifiedJEFFREY M. FAMELLI, O.D.
CASD0105820Medicare ID - Type UnspecifiedMARY E. DOUGHERTY, O.D.
CA0518290002Medicare NSC
CAU59123Medicare UPIN
CAT10657Medicare UPIN
CAZZZ26218ZMedicare PIN
CAT10437Medicare UPIN
CASD0069090Medicare ID - Type UnspecifiedLARRY R. FABIAN, O.D.