Provider Demographics
NPI:1295775047
Name:WAKAYAMA, KAREN TOKI (OD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:TOKI
Last Name:WAKAYAMA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:K
Other - Last Name:TOKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:17300 17TH ST STE M
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1955
Mailing Address - Country:US
Mailing Address - Phone:714-838-9664
Mailing Address - Fax:714-838-6774
Practice Address - Street 1:17300 17TH ST STE M
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1955
Practice Address - Country:US
Practice Address - Phone:714-838-9664
Practice Address - Fax:714-838-6774
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8038T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFQ169ZMedicare PIN