Provider Demographics
NPI:1205198520
Name:CONNIE K HA OD, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CONNIE K HA OD, PROFESSIONAL CORPORATION
Other - Org Name:SAN BRUNO EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:650-588-7701
Mailing Address - Street 1:931 SAN BRUNO AVE W RM 4
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3435
Mailing Address - Country:US
Mailing Address - Phone:650-588-7701
Mailing Address - Fax:650-588-7797
Practice Address - Street 1:931 SAN BRUNO AVE W RM 4
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3435
Practice Address - Country:US
Practice Address - Phone:650-588-7701
Practice Address - Fax:650-588-7797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGZ978AMedicare PIN
CASD0111410Medicare UPIN