Provider Demographics
NPI:1285781922
Name:WAKE, EUGENE L (OD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:L
Last Name:WAKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1620 SARATOGA AVE # P-301
Mailing Address - Street 2:WESTGATE S C
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-5113
Mailing Address - Country:US
Mailing Address - Phone:408-371-5180
Mailing Address - Fax:408-371-5154
Practice Address - Street 1:1689 ARDEN WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4030
Practice Address - Country:US
Practice Address - Phone:916-648-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU30704Medicare UPIN