Provider Demographics
NPI:1356577217
Name:KUBOTA, CARRIE R (OD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:R
Last Name:KUBOTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1197 E LOS ANGELES AVE STE D
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2868
Mailing Address - Country:US
Mailing Address - Phone:805-577-9177
Mailing Address - Fax:805-577-8220
Practice Address - Street 1:1197 E LOS ANGELES AVE STE D
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2868
Practice Address - Country:US
Practice Address - Phone:805-577-9177
Practice Address - Fax:805-577-8220
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9907TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP9907AMedicare UPIN