MEDICARE: DR. SANDRA DESELLE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	12111-T	CA
2	152W00000X	Optometrist	1098	NV

General Provider Information

NPI Number	:	1164402608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA DESELLE O.D.

Provider Business Mailing Address
First Line	:	215 MAIN ST
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94022-2909
Country	:	US
Telephone Number	:	650-947-3937
Fax Number	:	650-947-3935

Provider Business Practice Location Address
First Line	:	1987 N CARSON ST STE 5
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-1225
Country	:	US
Telephone Number	:	775-883-2015
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	10/11/2023

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