Provider Demographics
NPI:1740344472
Name:MIYASAKI, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:MIYASAKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MONUMENT BLVD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3105
Mailing Address - Country:US
Mailing Address - Phone:925-671-7799
Mailing Address - Fax:925-671-9944
Practice Address - Street 1:2400 MONUMENT BLVD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-3105
Practice Address - Country:US
Practice Address - Phone:925-671-7799
Practice Address - Fax:925-671-9944
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist