Provider Demographics
NPI:1912050055
Name:FALLEJO, SAMUEL N (OD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:N
Last Name:FALLEJO
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 1:395 HICKEY BLVD
Mailing Address - Street 2:EYE SERVICES DEPT, 5TH FLOOR
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2770
Mailing Address - Country:US
Mailing Address - Phone:650-301-5873
Mailing Address - Fax:
Practice Address - Street 1:395 HICKEY BLVD
Practice Address - Street 2:EYE SERVICES DEPT, 5TH FLOOR
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2770
Practice Address - Country:US
Practice Address - Phone:650-301-5873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10885T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist