Provider Demographics
NPI:1992856298
Name:NINOMIYA, SANDRA AKEMI (OD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:AKEMI
Last Name:NINOMIYA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:AKEMI
Other - Last Name:FUKUSHIMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1040 E IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5614
Mailing Address - Country:US
Mailing Address - Phone:714-990-5777
Mailing Address - Fax:
Practice Address - Street 1:1 MILLS CIR
Practice Address - Street 2:ONTARIO MILLS #516
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5207
Practice Address - Country:US
Practice Address - Phone:909-484-9722
Practice Address - Fax:909-484-3394
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10760T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU68499Medicare UPIN
CAWOP10760Medicare ID - Type Unspecified