Provider Demographics
NPI:1376628404
Name:BURKE, GERMAINE NOEL (OD)
Entity Type:Individual
Prefix:DR
First Name:GERMAINE
Middle Name:NOEL
Last Name:BURKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:GERMAINE
Other - Middle Name:NOEL
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:441 S. HAM LANE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242
Mailing Address - Country:US
Mailing Address - Phone:209-224-5454
Mailing Address - Fax:209-224-8791
Practice Address - Street 1:441 S HAM LN
Practice Address - Street 2:SUITE B
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3525
Practice Address - Country:US
Practice Address - Phone:209-224-5454
Practice Address - Fax:209-224-8791
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9259T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0092590Medicaid
CASD0092590Medicaid
CASD0092590Medicare ID - Type Unspecified