Healthcare Provider Details

I. General information

NPI: 1174048698
Provider Name (Legal Business Name): KRISTEN YING ODA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2017
Last Update Date: 08/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 JACKSON ST
SAN JOSE CA
95112-3201
US

IV. Provider business mailing address

1122 KOVANDA WAY
MILPITAS CA
95035-3130
US

V. Phone/Fax

Practice location:
  • Phone: 408-293-3730
  • Fax:
Mailing address:
  • Phone: 408-420-6925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33814LTG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: