MEDICARE: KOSOL VIPAPAN 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	OPT10602TPA	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366552432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOSOL VIPAPAN O.D.

Provider Business Mailing Address
First Line	:	1400 BELLWOOD RD
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2713
Country	:	US
Telephone Number	:	626-379-9927
Fax Number	:	626-792-9993

Provider Business Practice Location Address
First Line	:	1136 E GREEN ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-2500
Country	:	US
Telephone Number	:	626-792-9979
Fax Number	:

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	04/16/2021

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