Provider Demographics
NPI:1922127356
Name:BROOKSIDE OPTOMETRIC GROUP
Entity Type:Organization
Organization Name:BROOKSIDE OPTOMETRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:HISAKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-951-0820
Mailing Address - Street 1:3133 W MARCH LN STE 2020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3133 W MARCH LN STE 2020
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2361
Practice Address - Country:US
Practice Address - Phone:209-951-0820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0059260Medicaid
CASD0094740Medicaid
CASD0107720Medicaid
CASD0107720Medicaid
CA1922127356Medicare NSC
CASD0059260Medicare PIN
CASD0059260Medicaid
CASD0094740Medicare PIN
CASD0054040Medicare PIN
CASD0094740Medicaid
CAYYY49714YMedicare PIN
CASD0061970Medicare PIN
CA0694800001Medicare NSC
CASD0096520Medicare PIN
CASD0096670Medicare PIN