Provider Demographics
NPI:1790919108
Name:GLENN S NAKAYAMA OD
Entity Type:Organization
Organization Name:GLENN S NAKAYAMA OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:SHIGERU
Authorized Official - Last Name:NAKAYAMA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-289-9171
Mailing Address - Street 1:100 E HUNTINGTON DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1022
Mailing Address - Country:US
Mailing Address - Phone:626-289-9171
Mailing Address - Fax:626-289-1026
Practice Address - Street 1:100 E HUNTINGTON DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1022
Practice Address - Country:US
Practice Address - Phone:626-289-9171
Practice Address - Fax:626-289-1026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0209000001Medicare NSC