Provider Demographics
NPI:1033247457
Name:MCCOY, MAUREEN (OD)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CALEDONIA ST
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-2116
Mailing Address - Country:US
Mailing Address - Phone:415-331-0121
Mailing Address - Fax:415-331-0149
Practice Address - Street 1:33 CALEDONIA ST
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-2116
Practice Address - Country:US
Practice Address - Phone:415-331-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12409T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90-0160128OtherFEDERAL TAX ID
CA90-0160128OtherFEDERAL TAX ID
CA90-0160128OtherFEDERAL TAX ID
CAMM1000392OtherDEA NUMBER
CASDO24090Medicare ID - Type UnspecifiedUSE ON HFCA FORM
CA5518290001Medicare NSC