Provider Demographics
NPI:1740279207
Name:SYLVAN EYE ASSOCIATES, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SYLVAN EYE ASSOCIATES, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-575-2020
Mailing Address - Street 1:1011 SYLVAN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1692
Mailing Address - Country:US
Mailing Address - Phone:209-575-2020
Mailing Address - Fax:209-758-5693
Practice Address - Street 1:1011 SYLVAN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1692
Practice Address - Country:US
Practice Address - Phone:209-575-2020
Practice Address - Fax:209-758-5693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0088410OtherOPTHALMOLOGY MEDICAL
CAGSD088411Medicaid
ZZZ00823ZOtherBLUE SHIELD
CAZZZ18499ZMedicare PIN
CAGR0088410OtherOPTHALMOLOGY MEDICAL