Healthcare Provider Details

I. General information

NPI: 1124579404
Provider Name (Legal Business Name): DR GAUDREAU OPTOMETRY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 N SANTA CRUZ AVE
LOS GATOS CA
95030-5916
US

IV. Provider business mailing address

53 N SANTA CRUZ AVE
LOS GATOS CA
95030-5916
US

V. Phone/Fax

Practice location:
  • Phone: 408-399-8003
  • Fax: 408-399-8004
Mailing address:
  • Phone: 408-399-8003
  • Fax: 408-399-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14533TLG
License Number StateCA

VIII. Authorized Official

Name: DR. PARYA GAUDREAU
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 408-399-8003