Provider Demographics
NPI:1437882636
Name:KAGEYAMA, ANDREW HIROSHI (OD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:HIROSHI
Last Name:KAGEYAMA
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 1:9401 E STOCKTON BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-5050
Mailing Address - Country:US
Mailing Address - Phone:916-686-4937
Mailing Address - Fax:
Practice Address - Street 1:9401 E STOCKTON BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-5050
Practice Address - Country:US
Practice Address - Phone:916-686-4937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOEG003929OtherLICENSE