Active NPI
Eye Associates of Sebastopol Medical Group Inc
- Ophthalmology Physician
- Sebastopol, CA
National Provider Identifier
1295729382
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Ophthalmology Physician
- Legal business name
- EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP INC
- Practice address
- 6880 Palm Ave
Sebastopol, CA 95472-4270 - Phone
- (707) 823-7628
- Fax
- (707) 823-1521
- NPI assigned
- Sep 6, 2005
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Ms. Kim Khamthee
- Title
- Billing Manager
- Phone
- (707) 823-0229
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ophthalmology Physician | 207W00000X | Primary |
Addresses
Primary practice location
6880 Palm Ave
Sebastopol, CA 95472-4270
Mailing address
6880 Palm Ave
Sebastopol, CA 95472-4270
Phone (707) 823-7628
Other identifiers 9
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ZZZ16441Z | Other | CA | BLUE SHIELD |
| GR0083382 | Medicaid | CA | |
| 05D1077728 | Other | CA | CLIA |
| GR0083381 | Medicaid | CA | |
| GR0083383 | Medicaid | CA | |
| CI4202 | Other | CA | MEDICARE RET RAILROAD |
| 1247100001 | Other | CA | DMERC |
| ZZZ88771Z | Other | CA | BLUE SHIELD |
| GR0083380 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
Enrollment records 1
Other NPIs with the same Medicare PAC ID 1
NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).
-
- Eyewear Supplier
- Sebastopol, CA
- NPI 1619012119
1052362696
National Provider Directory
National Provider DirectoryLocations
4456 Manzanita Ave
#2
Clearlake, CA 95422
Phone (707) 461-5027
Practitioners & affiliated clinicians
Practitioners 13
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1125964800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1598918400000",
"number": "1295729382",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6880 PALM AVE",
"city": "SEBASTOPOL",
"state": "CA",
"postal_code": "954724270",
"telephone_number": "707-823-7628",
"fax_number": "707-823-1521"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6880 PALM AVE",
"city": "SEBASTOPOL",
"state": "CA",
"postal_code": "954724270",
"telephone_number": "707-823-7628",
"fax_number": "707-823-1521"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP INC",
"organizational_subpart": "NO",
"enumeration_date": "2005-09-06",
"last_updated": "2020-09-01",
"certification_date": "2020-08-21",
"status": "A",
"authorized_official_last_name": "KHAMTHEE",
"authorized_official_first_name": "KIM",
"authorized_official_title_or_position": "BILLING MANAGER",
"authorized_official_telephone_number": "707-823-0229",
"authorized_official_name_prefix": "Ms."
},
"taxonomies": [
{
"code": "207W00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Ophthalmology",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE SHIELD",
"identifier": "ZZZ16441Z",
"state": "CA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "GR0083382",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CLIA",
"identifier": "05D1077728",
"state": "CA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "GR0083381",
"state": "CA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "GR0083383",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE RET RAILROAD",
"identifier": "CI4202",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DMERC",
"identifier": "1247100001",
"state": "CA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE SHIELD",
"identifier": "ZZZ88771Z",
"state": "CA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "GR0083380",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Sebastopol, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.