Healthcare Provider Details

I. General information

NPI: 1417945163
Provider Name (Legal Business Name): BENJAMIN WAYNE POPILSKY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7551 SOQUEL DR
APTOS CA
95003-3815
US

IV. Provider business mailing address

7551 SOQUEL DR
APTOS CA
95003-3815
US

V. Phone/Fax

Practice location:
  • Phone: 831-688-2020
  • Fax: 831-688-2036
Mailing address:
  • Phone: 831-688-2020
  • Fax: 831-688-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT9073TPG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: