Provider Demographics
NPI:1457425852
Name:STANISLAUS VISION ASSOCIATES OPTOMETRIC GROUP INC
Entity type:Organization
Organization Name:STANISLAUS VISION ASSOCIATES OPTOMETRIC GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:H
Authorized Official - Last Name:WHATCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-524-4626
Mailing Address - Street 1:1700 MCHENRY AVENUE
Mailing Address - Street 2:SUITE 77
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4318
Mailing Address - Country:US
Mailing Address - Phone:209-524-4626
Mailing Address - Fax:209-524-1046
Practice Address - Street 1:1700 MCHENRY AVENUE
Practice Address - Street 2:SUITE 77
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4318
Practice Address - Country:US
Practice Address - Phone:209-524-4626
Practice Address - Fax:209-524-1046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOR15152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ST1529366OtherCLARITY VISION
02421OtherMEDICAL EYE SERVICES
CAGSD000120Medicaid
02421OtherMEDICAL EYE SERVICES
=========OtherSTANISLAUS FOUNDATION MED
=========OtherAETNA
=========95350OtherTRICARE
CAZZZ80215ZMedicare PIN
=========95350OtherTRICARE
CP3004Medicare PIN