Provider Demographics
NPI:1013922665
Name:KUMABE, CARRIE W (OD)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:W
Last Name:KUMABE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CARRIE
Other - Middle Name:S
Other - Last Name:WAKAI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3756 SANTA ROSALIA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3606
Mailing Address - Country:US
Mailing Address - Phone:323-294-7517
Mailing Address - Fax:323-294-9219
Practice Address - Street 1:3756 SANTA ROSALIA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3606
Practice Address - Country:US
Practice Address - Phone:323-294-7517
Practice Address - Fax:323-294-9219
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8343T152W00000X
HI232T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0083430Medicaid
CAU45323Medicare UPIN