Provider Demographics
NPI:1255366829
Name:KITA, TETSUJI C (OD)
Entity type:Individual
Prefix:DR
First Name:TETSUJI
Middle Name:C
Last Name:KITA
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 1:1255 ROBLE RD
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-2938
Mailing Address - Country:US
Mailing Address - Phone:650-259-9518
Mailing Address - Fax:
Practice Address - Street 1:1322 BROADWAY
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3426
Practice Address - Country:US
Practice Address - Phone:650-343-4916
Practice Address - Fax:650-343-6920
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10704T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0107040Medicaid
CASD0107040Medicaid
CABT858AMedicare PIN