Healthcare Provider Details

I. General information

NPI: 1396778718
Provider Name (Legal Business Name): MEDICAL VISION TECHNOLOGY OPHTHALMOLOGY MEDICAL GRP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 ANDERSON RD SUITE 1
DAVIS CA
95616-3505
US

IV. Provider business mailing address

1700 ALHAMBRA BLVD SUITE 202
SACRAMENTO CA
95816-7050
US

V. Phone/Fax

Practice location:
  • Phone: 530-756-5040
  • Fax: 530-756-9140
Mailing address:
  • Phone: 916-731-8040
  • Fax: 916-454-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOANN MUSHOLT
Title or Position: BILLING MANAGER
Credential:
Phone: 916-731-5955