MEDICARE: DR. RAYMOND F PEDERSEN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	8564T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457343717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAYMOND F PEDERSEN OD

Provider Business Mailing Address
First Line	:	38069 MARTHA AVE
Second Line	:	SUITE 200
City	:	FREMONT
State	:	CA
Zip	:	94536-3811
Country	:	US
Telephone Number	:	510-791-5272
Fax Number	:	510-791-0660

Provider Business Practice Location Address
First Line	:	38069 MARTHA AVE
Second Line	:	SUITE 200
City	:	FREMONT
State	:	CA
Zip	:	94536-3811
Country	:	US
Telephone Number	:	510-791-5272
Fax Number	:	510-791-0660

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	02/10/2016

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