Provider Demographics
NPI:1053607713
Name:URSULA MOONSAMY
Entity type:Organization
Organization Name:URSULA MOONSAMY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:URSULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONSAMY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-832-3937
Mailing Address - Street 1:3341 LAKESHORE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2305
Mailing Address - Country:US
Mailing Address - Phone:510-832-3937
Mailing Address - Fax:510-832-5166
Practice Address - Street 1:3341 LAKESHORE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2305
Practice Address - Country:US
Practice Address - Phone:510-832-3937
Practice Address - Fax:510-832-5166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFH848AMedicare PIN