Provider Demographics
NPI:1922046994
Name:OZAWA, GLEN YUKIO (OD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:YUKIO
Last Name:OZAWA
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 1:65 THORNTON ST
Mailing Address - Street 2:308
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4836
Mailing Address - Country:US
Mailing Address - Phone:510-614-1084
Mailing Address - Fax:
Practice Address - Street 1:4598 S TRACY BLVD
Practice Address - Street 2:130
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8106
Practice Address - Country:US
Practice Address - Phone:209-835-1181
Practice Address - Fax:209-835-9396
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 00011802T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABP271ZMedicaid
CAU89046Medicare UPIN
BP271ZMedicare PIN