Provider Demographics
NPI:1437297173
Name:NAKAMOTO, MARVIN S (OD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:S
Last Name:NAKAMOTO
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 1:2131 CAPITOL AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5755
Mailing Address - Country:US
Mailing Address - Phone:916-446-0125
Mailing Address - Fax:916-446-3586
Practice Address - Street 1:2131 CAPITOL AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5755
Practice Address - Country:US
Practice Address - Phone:916-446-0125
Practice Address - Fax:916-446-3586
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8551 TPA152W00000X
CA8551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0085510Medicaid
CA02813OtherMEDICAL EYE SERVICES
CAT10703Medicare UPIN
CASD0085510Medicaid