Provider Demographics
NPI:1992944185
Name:KAREN GRIFFITH OD A PROFESSIONAL OPTOMETRY CORPORATION
Entity type:Organization
Organization Name:KAREN GRIFFITH OD A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-762-8643
Mailing Address - Street 1:320 PETALUMA BLVD S
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4245
Mailing Address - Country:US
Mailing Address - Phone:707-762-8643
Mailing Address - Fax:
Practice Address - Street 1:320 PETALUMA BLVD S
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4245
Practice Address - Country:US
Practice Address - Phone:707-762-8643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9002TL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6194620001Medicare NSC
CABO099Medicare PIN