Provider Demographics
NPI:1457343717
Name:PEDERSEN, RAYMOND F (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:F
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:RAYMOND
Other - Middle Name:F
Other - Last Name:PEDERSEN OD PROFESSIONAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:38069 MARTHA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3811
Mailing Address - Country:US
Mailing Address - Phone:510-791-5272
Mailing Address - Fax:510-791-0660
Practice Address - Street 1:38069 MARTHA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3811
Practice Address - Country:US
Practice Address - Phone:510-791-5272
Practice Address - Fax:510-791-0660
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8564T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0085640Medicaid
T10705Medicare UPIN
CASD0085640Medicare ID - Type Unspecified
CA0155230001Medicare NSC