Provider Demographics
NPI:1770747701
Name:TALAGA, KEVIN C (OD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:TALAGA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-7758
Mailing Address - Country:US
Mailing Address - Phone:415-713-9221
Mailing Address - Fax:
Practice Address - Street 1:3000 Q ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-7058
Practice Address - Country:US
Practice Address - Phone:916-733-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2062152W00000X
CAOPT 13654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist