Provider Demographics
NPI:1922092022
Name:KOSAKURA, KEITH H (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:H
Last Name:KOSAKURA
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 1:19998 HOMESTEAD RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-0569
Mailing Address - Country:US
Mailing Address - Phone:408-257-5262
Mailing Address - Fax:408-257-8271
Practice Address - Street 1:19998 HOMESTEAD RD
Practice Address - Street 2:SUITE E
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-0569
Practice Address - Country:US
Practice Address - Phone:408-257-5262
Practice Address - Fax:408-257-8271
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10854T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU75880Medicare UPIN
CA4087570001Medicare NSC
CASD0108540Medicare PIN