Healthcare Provider Details

I. General information

NPI: 1124949201
Provider Name (Legal Business Name): MAKAYLA MARY KOOCHOU OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 FILLMORE ST
SAN FRANCISCO CA
94115-2706
US

IV. Provider business mailing address

1907 FILLMORE ST
SAN FRANCISCO CA
94115-2706
US

V. Phone/Fax

Practice location:
  • Phone: 415-563-9003
  • Fax: 415-563-9006
Mailing address:
  • Phone: 209-640-8590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: