Provider Demographics
NPI:1952375172
Name:KOGA, IRENE (OD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KOGA
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 1:34 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102
Mailing Address - Country:US
Mailing Address - Phone:415-431-3100
Mailing Address - Fax:415-431-1010
Practice Address - Street 1:34 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102
Practice Address - Country:US
Practice Address - Phone:415-431-3100
Practice Address - Fax:415-431-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8765T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5457040001Medicare NSC
U25693Medicare UPIN
ZZZ32442ZMedicare ID - Type Unspecified