Healthcare Provider Details

I. General information

NPI: 1891839130
Provider Name (Legal Business Name): MILPITAS OPTOMETRIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E CALAVERAS BLVD
MILPITAS CA
95035-5543
US

IV. Provider business mailing address

1301 E CALAVERAS BLVD
MILPITAS CA
95035-5543
US

V. Phone/Fax

Practice location:
  • Phone: 408-263-2040
  • Fax: 408-946-2020
Mailing address:
  • Phone: 408-263-2040
  • Fax: 408-946-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN G GORDON
Title or Position: TREASUROR
Credential: O.D.
Phone: 408-263-2040