Basic Information
| Provider Information | |||||||||
| NPI: | 1083747893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICETTI | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 SOUTH SIERRA AVE | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953614093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098451346 | ||||||||
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| Practice Location | |||||||||
| Address1: | 302 SILVER AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941121510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153342506 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | A16579 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00A165791 | 05 | CA | MEDICAID |