Healthcare Provider Details

I. General information

NPI: 1043628548
Provider Name (Legal Business Name): AMANDEEP SAPPAL O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 TRAVIS BLVD UNIT 1507A
FAIRFIELD CA
94533-3440
US

IV. Provider business mailing address

1160 MARLOWE CT
VACAVILLE CA
95687-5265
US

V. Phone/Fax

Practice location:
  • Phone: 707-421-2020
  • Fax:
Mailing address:
  • Phone: 707-474-7571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number15057TLG
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number15057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: