Healthcare Provider Details

I. General information

NPI: 1811124316
Provider Name (Legal Business Name): KEITH KOSAKURA, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19998 HOMESTEAD RD SUITE E
CUPERTINO CA
95014-0569
US

IV. Provider business mailing address

19998 HOMESTEAD RD SUITE E
CUPERTINO CA
95014-0569
US

V. Phone/Fax

Practice location:
  • Phone: 408-257-5262
  • Fax: 408-257-8271
Mailing address:
  • Phone: 408-257-5262
  • Fax: 408-257-8271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number10854 T
License Number StateCA

VIII. Authorized Official

Name: DR. KEITH H KOSAKURA
Title or Position: OWNER
Credential: O.D.
Phone: 408-257-5262