1922046994 NPI number — DR. GLEN YUKIO OZAWA O.D.

Table of content: DR. GLEN YUKIO OZAWA O.D. (NPI 1922046994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922046994 NPI number — DR. GLEN YUKIO OZAWA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OZAWA
Provider First Name:
GLEN
Provider Middle Name:
YUKIO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922046994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65 THORNTON ST
Provider Second Line Business Mailing Address:
308
Provider Business Mailing Address City Name:
SAN LEANDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94577-4836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-614-1084
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4598 S TRACY BLVD
Provider Second Line Business Practice Location Address:
130
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95377-8106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-835-1181
Provider Business Practice Location Address Fax Number:
209-835-9396
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT 00011802T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BP271Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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