Healthcare Provider Details

I. General information

NPI: 1356078265
Provider Name (Legal Business Name): PAYAL BAVISHI OD PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 FRANCISCO LN
FREMONT CA
94539-7926
US

IV. Provider business mailing address

4627 DRURY CT
FREMONT CA
94538-3321
US

V. Phone/Fax

Practice location:
  • Phone: 510-490-0287
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: PAYAL BAVISHI
Title or Position: PRESIDENT
Credential: OD
Phone: 510-371-1411