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General NPI Number Information
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NPI Number | 1689707713
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Entity Type | Individual
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Provider Name | MARK SHIGEO KOMURE O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 10/02/2009
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Provider Practice Location Address
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Address Line | 2087 GRAND CANAL BLVD STE 15
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City | STOCKTON
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State | CA
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Zip | 95207-6651
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Country | US
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Telephone | 209-477-0296
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Fax | 209-478-7322
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Provider Business Mailing Address
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Address Line | 2087 GRAND CANAL BLVD STE 15
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City | STOCKTON
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State | CA
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Zip | 95207-6651
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Country | US
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Telephone | 209-477-0296
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Fax | 209-478-7322
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 6480T
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License Number State | CA
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