=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235902800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. VIDENNE SATH, OPTOMETRY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2023
-----------------------------------------------------
Last Update Date | 02/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3412 COLLEGE AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92115-7134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-286-1291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3634 OLD COBBLE RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92111-4048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-895-1684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | DR. VIDENNE SATH
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 562-895-1684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------