Provider Demographics
NPI:1073550976
Name:WAKAMATSU, HERBERT KEIJI (OD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:KEIJI
Last Name:WAKAMATSU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16302 HEARTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-6516
Mailing Address - Country:US
Mailing Address - Phone:562-279-5406
Mailing Address - Fax:213-384-2002
Practice Address - Street 1:3525 W 8TH ST
Practice Address - Street 2:#228B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-2993
Practice Address - Country:US
Practice Address - Phone:213-380-2831
Practice Address - Fax:213-384-2002
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5224T152W00000X
CAOPT 5224T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV10092Medicare UPIN
CAOP5224Medicare PIN