MEDICARE: DR. LISA K. KO O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	10352T	CA

General Provider Information

NPI Number	:	1316967391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA K. KO O.D.

Provider Business Mailing Address
First Line	:	618 BLOSSOM HILL RD
Second Line	:	100
City	:	SAN JOSE
State	:	CA
Zip	:	95123-3048
Country	:	US
Telephone Number	:	408-578-2020
Fax Number	:	408-904-5119

Provider Business Practice Location Address
First Line	:	618 BLOSSOM HILL RD
Second Line	:	100
City	:	SAN JOSE
State	:	CA
Zip	:	95123-3048
Country	:	US
Telephone Number	:	408-578-2020
Fax Number	:	408-904-5119

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	02/05/2010

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