MEDICARE: DR. CARRIE R KUBOTA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT9907TPA	CA

General Provider Information

NPI Number	:	1356577217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARRIE R KUBOTA O.D.

Provider Business Mailing Address
First Line	:	1197 E LOS ANGELES AVE STE D
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-2868
Country	:	US
Telephone Number	:	805-577-9177
Fax Number	:	805-577-8220

Provider Business Practice Location Address
First Line	:	1197 E LOS ANGELES AVE STE D
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-2868
Country	:	US
Telephone Number	:	805-577-9177
Fax Number	:	805-577-8220

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2009
Last Update Date	:	06/05/2009

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