Provider Demographics
NPI:1063454130
Name:NA, BENJAMIN HANBOK (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:HANBOK
Last Name:NA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:HANBOK
Other - Middle Name:BENJAMIN
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3191 CROW CANYON PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1349
Mailing Address - Country:US
Mailing Address - Phone:925-244-1400
Mailing Address - Fax:925-244-1414
Practice Address - Street 1:3191 CROW CANYON PL
Practice Address - Street 2:SUITE C
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1349
Practice Address - Country:US
Practice Address - Phone:925-244-1400
Practice Address - Fax:925-244-1414
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11709TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117090Medicaid
CABP257AMedicare UPIN
CABP257BMedicare UPIN
SD0117090Medicare PIN
CABP257AMedicare PIN
CABP257BMedicare PIN
CAU91271Medicare UPIN
5866410001Medicare NSC
CASD0117090Medicare PIN
5866410002Medicare NSC