Provider Demographics
NPI:1730253287
Name:SACRAMENTO EYE CONSULTANTS A MED CORP
Entity type:Organization
Organization Name:SACRAMENTO EYE CONSULTANTS A MED CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:WELLINGTON
Authorized Official - Last Name:BRUBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-649-1515
Mailing Address - Street 1:1515 RESPONSE RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4805
Mailing Address - Country:US
Mailing Address - Phone:916-649-1515
Mailing Address - Fax:916-649-1516
Practice Address - Street 1:1515 RESPONSE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4805
Practice Address - Country:US
Practice Address - Phone:916-649-1515
Practice Address - Fax:916-649-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207W00000X
152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102650Medicaid
CAZZZ14936ZMedicare PIN