Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 10517T | CA |
NPI | 1013068576 |
---|---|
Provider Name | Mr. Russell Brian Ng |
First Address | Sacramento, CA 95842-2526 |
Second Address | Sacramento, CA 95842-2526 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2007 |
Last Update Date | 16/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
SD0105170 | (05) | CA |
U64580 | (02) | CA |