Provider Demographics
NPI:1679601066
Name:PETER W ROSS OD & LARRY K WAN OD INC
Entity type:Organization
Organization Name:PETER W ROSS OD & LARRY K WAN OD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-866-2020
Mailing Address - Street 1:338 E HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0207
Mailing Address - Country:US
Mailing Address - Phone:408-866-2020
Mailing Address - Fax:408-370-3937
Practice Address - Street 1:338 E HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0207
Practice Address - Country:US
Practice Address - Phone:408-866-2020
Practice Address - Fax:408-370-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22243ZOtherPTAN
CAZZZ64079ZOtherBLUE SHIELD OF CA
CA0203170001Medicare NSC