Basic Information
| Provider Information | |||||||||
| NPI: | 1902466659 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SINSONGSERM | ||||||||
| FirstName: | BOBBY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13724 EL ESPEJO RD | ||||||||
| Address2: | |||||||||
| City: | LA MIRADA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906383718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624476307 | ||||||||
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| Practice Location | |||||||||
| Address1: | 483 W SEED FARM RD | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205623321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2019 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | OPT-002365 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.