Provider Demographics
NPI:1568455277
Name:KITAHATA, MIKI (OD)
Entity Type:Individual
Prefix:DR
First Name:MIKI
Middle Name:
Last Name:KITAHATA
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 1:427 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2136
Mailing Address - Country:US
Mailing Address - Phone:630-232-7112
Mailing Address - Fax:630-232-7160
Practice Address - Street 1:427 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2136
Practice Address - Country:US
Practice Address - Phone:630-232-7112
Practice Address - Fax:630-232-7160
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-27
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46008170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist