Provider Demographics
NPI:1659387793
Name:YAMADA, GARY S (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:YAMADA
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 1:4433 FLORIN RD
Mailing Address - Street 2:SUITE #890
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2527
Mailing Address - Country:US
Mailing Address - Phone:916-393-5151
Mailing Address - Fax:916-392-6130
Practice Address - Street 1:4433 FLORIN RD
Practice Address - Street 2:SUITE #890
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2527
Practice Address - Country:US
Practice Address - Phone:916-393-5151
Practice Address - Fax:916-392-6130
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05232T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0052320Medicaid
CASD0052320Medicaid