Provider Demographics
NPI:1427185990
Name:RICHARD J. MIYAMOTO, O.D
Entity Type:Organization
Organization Name:RICHARD J. MIYAMOTO, O.D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MIYAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-538-3937
Mailing Address - Street 1:18525 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3830
Mailing Address - Country:US
Mailing Address - Phone:310-538-3937
Mailing Address - Fax:310-538-6952
Practice Address - Street 1:18525 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3830
Practice Address - Country:US
Practice Address - Phone:310-538-3937
Practice Address - Fax:310-538-6952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7016TPA152W00000X
CA10386TPA152W00000X
CA11361TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070160Medicaid
CAT70168Medicare UPIN
CAT70168Medicare ID - Type Unspecified
CA0991650001Medicare NSC