Provider Demographics
NPI:1063417814
Name:SEVERIN, SANFORD LEWIS (MD)
Entity type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:LEWIS
Last Name:SEVERIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5801 NORRIS CANYON RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5440
Mailing Address - Country:US
Mailing Address - Phone:925-830-8823
Mailing Address - Fax:925-866-6610
Practice Address - Street 1:5801 NORRIS CANYON RD
Practice Address - Street 2:STE 200
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5440
Practice Address - Country:US
Practice Address - Phone:925-830-8823
Practice Address - Fax:925-866-6610
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAOOC236190207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0708OtherMEDICAL EYE SERVICES
CACGP164916Medicaid
CAZZZ057067OtherBLUE CROSS
CAZZZ05706ZOtherBLUE SHIELD
CA180046438OtherRAIL ROAD MEDICARE
CAA32449Medicare UPIN
CAA32449Medicare UPIN