Provider Demographics
NPI:1487601522
Name:SPECTRUM EYE PHYSICIANS, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SPECTRUM EYE PHYSICIANS, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:COE
Authorized Official - Phone:408-252-7310
Mailing Address - Street 1:10300 S DE ANZA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3030
Mailing Address - Country:US
Mailing Address - Phone:408-253-3083
Mailing Address - Fax:408-253-2965
Practice Address - Street 1:10300 S DE ANZA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3030
Practice Address - Country:US
Practice Address - Phone:408-253-3083
Practice Address - Fax:408-253-2965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13831 TLG152W00000X
CASRYGH 97-67584700006332H00000X
CA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0103602Medicaid
CAGR0103600Medicaid
CAGR0103601Medicaid
CAGR0103603Medicaid
CAGR0103603Medicaid
CAMMM00380MMedicare PIN
CAGR0103602Medicaid
CAGR0103600Medicaid
CA1004980001Medicare NSC