Provider Demographics
NPI:1841318540
Name:CRAIG K HISAKA OD MPH PROFESSIONAL OPTOMETRIC CORP
Entity type:Organization
Organization Name:CRAIG K HISAKA OD MPH PROFESSIONAL OPTOMETRIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:HISAKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-951-0820
Mailing Address - Street 1:3133 W MARCH LN STE 2020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3133 W MARCH LN STE 2020
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2361
Practice Address - Country:US
Practice Address - Phone:209-951-0820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0096520Medicaid
CASD0096520Medicaid
CAEF893AMedicare PIN