Provider Demographics
NPI:1700807369
Name:HA, CONNIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:HA
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 1:931 SAN BRUNO AVE W RM 4
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3435
Mailing Address - Country:US
Mailing Address - Phone:650-588-7701
Mailing Address - Fax:650-588-7797
Practice Address - Street 1:931 SAN BRUNO AVE W RM 4
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3435
Practice Address - Country:US
Practice Address - Phone:650-588-7701
Practice Address - Fax:650-588-7797
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGZ985ZMedicare PIN
CASD0111410Medicare UPIN