Provider Demographics
NPI:1750351268
Name:LONGACRE, AMY LIU LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:AMY LIU
Middle Name:LYNN
Last Name:LONGACRE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3591 CRESPI CT
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-7561
Mailing Address - Country:US
Mailing Address - Phone:925-463-2150
Mailing Address - Fax:925-463-1186
Practice Address - Street 1:6155 STONERIDGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3204
Practice Address - Country:US
Practice Address - Phone:925-463-2150
Practice Address - Fax:925-463-1186
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7518TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680505388OtherGROUPS FED'S ID NUMBER
CASD0009280Medicaid
CASD0009280Medicaid