Provider Demographics
NPI:1811124316
Name:KEITH KOSAKURA, O.D.
Entity type:Organization
Organization Name:KEITH KOSAKURA, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:H
Authorized Official - Last Name:KOSAKURA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-257-5262
Mailing Address - Street 1:19998 HOMESTEAD RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-0569
Mailing Address - Country:US
Mailing Address - Phone:408-257-5262
Mailing Address - Fax:408-257-8271
Practice Address - Street 1:19998 HOMESTEAD RD
Practice Address - Street 2:SUITE E
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-0569
Practice Address - Country:US
Practice Address - Phone:408-257-5262
Practice Address - Fax:408-257-8271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10854 T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4087580001Medicare NSC