Provider Demographics
NPI:1801910724
Name:DR SARAH K ITO O D A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DR SARAH K ITO O D A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ITO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-452-1039
Mailing Address - Street 1:2605 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4619
Mailing Address - Country:US
Mailing Address - Phone:310-452-1039
Mailing Address - Fax:310-452-1831
Practice Address - Street 1:2605 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-4619
Practice Address - Country:US
Practice Address - Phone:310-452-1039
Practice Address - Fax:310-452-1831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-17
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10084T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0100840Medicaid
BX931AMedicare PIN
CASD0100840Medicaid