Healthcare Provider Details

I. General information

NPI: 1417243205
Provider Name (Legal Business Name): ROBERT YUKIO OMOTO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7410 GREENHAVEN DR SUITE 140
SACRAMENTO CA
95831-5158
US

IV. Provider business mailing address

7410 GREENHAVEN DR SUITE 140
SACRAMENTO CA
95831-5158
US

V. Phone/Fax

Practice location:
  • Phone: 916-421-1278
  • Fax: 916-421-5055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14147
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number14147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: