Healthcare Provider Details

I. General information

NPI: 1790694602
Provider Name (Legal Business Name): HARSIMRAN KHALSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 MARKET PL
SAN RAMON CA
94583-4741
US

IV. Provider business mailing address

4710 W PELTIER RD
LODI CA
95242-9623
US

V. Phone/Fax

Practice location:
  • Phone: 925-275-0202
  • Fax:
Mailing address:
  • Phone: 510-566-2923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: