Provider Demographics
NPI:1346233798
Name:KOYAMA, SANFORD GERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:GERRY
Last Name:KOYAMA
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 1:18430 BROOKHURST ST
Mailing Address - Street 2:STE 100
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6726
Mailing Address - Country:US
Mailing Address - Phone:714-968-9121
Mailing Address - Fax:
Practice Address - Street 1:18430 BROOKHURST ST
Practice Address - Street 2:STE 100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6726
Practice Address - Country:US
Practice Address - Phone:714-968-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4979TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP4979Medicare PIN
CA4336750001Medicare NSC