Provider Demographics
NPI:1255409595
Name:AVAK, SERGE G (OD)
Entity type:Individual
Prefix:
First Name:SERGE
Middle Name:G
Last Name:AVAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 BURMAN DR
Mailing Address - Street 2:AVAK'S EYE CARE INSIDE TARGET
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-9275
Mailing Address - Country:US
Mailing Address - Phone:708-308-8892
Mailing Address - Fax:209-344-3896
Practice Address - Street 1:3000 COUNTRYSIDE DR
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-8402
Practice Address - Country:US
Practice Address - Phone:209-216-4042
Practice Address - Fax:209-634-4389
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2710-035152W00000X
CA12194 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU74023Medicare UPIN