Provider Demographics
NPI:1689707713
Name:KOMURE, MARK SHIGEO (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SHIGEO
Last Name:KOMURE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2087 GRAND CANAL BLVD STE 15
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6651
Mailing Address - Country:US
Mailing Address - Phone:209-477-0296
Mailing Address - Fax:209-478-7322
Practice Address - Street 1:2087 GRAND CANAL BLVD STE 15
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6651
Practice Address - Country:US
Practice Address - Phone:209-477-0296
Practice Address - Fax:209-478-7322
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6480T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1930714Medicaid
CA3647260001Medicare NSC
CA1689707713Medicare PIN
CA1930714Medicaid
CA410015790Medicare PIN
CAT10334Medicare UPIN