Provider Demographics
NPI:1386638609
Name:TSUKAMOTO, DIANA KIYOME (OD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:KIYOME
Last Name:TSUKAMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20363 CLIFDEN WAY
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-4460
Mailing Address - Country:US
Mailing Address - Phone:408-257-4171
Mailing Address - Fax:
Practice Address - Street 1:10123 N WOLFE RD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2513
Practice Address - Country:US
Practice Address - Phone:408-446-4004
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA12665T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV01161Medicare UPIN