Provider Demographics
NPI:1720301260
Name:SERGIOUS, SOBHY
Entity Type:Individual
Prefix:
First Name:SOBHY
Middle Name:
Last Name:SERGIOUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 BOLLINGER CANYON RD
Mailing Address - Street 2:SUIT C
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5075
Mailing Address - Country:US
Mailing Address - Phone:925-964-1010
Mailing Address - Fax:925-964-1011
Practice Address - Street 1:11000 BOLLINGER CANYON RD
Practice Address - Street 2:SUIT C
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-5075
Practice Address - Country:US
Practice Address - Phone:925-964-1010
Practice Address - Fax:925-964-1011
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL5945156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician