Healthcare Provider Details

I. General information

NPI: 1659688182
Provider Name (Legal Business Name): LISA KIT YI KO OPTOMETRIST INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 BLOSSOM HILL RD SUITE 100
SAN JOSE CA
95123-3048
US

IV. Provider business mailing address

618 BLOSSOM HILL RD SUITE 100
SAN JOSE CA
95123-3048
US

V. Phone/Fax

Practice location:
  • Phone: 408-578-2020
  • Fax: 408-904-5119
Mailing address:
  • Phone: 408-578-2020
  • Fax: 408-904-5119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number10352T
License Number StateCA

VIII. Authorized Official

Name: DR. LISA KO
Title or Position: OWNER
Credential: O.D.
Phone: 408-578-2020