MEDICARE: CRAIG K HISAKA OD MPH PROFESSIONAL OPTOMETRIC CORP

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

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	:	1841318540
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRAIG K HISAKA OD MPH PROFESSIONAL OPTOMETRIC CORP

Provider Business Mailing Address
First Line	:	3133 W MARCH LN STE 2020
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-2361
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3133 W MARCH LN STE 2020
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-2361
Country	:	US
Telephone Number	:	209-951-0820
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CRAIG HISAKA
Credential	:	O.D.
Telephone Number	:	209-951-0820

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	04/08/2011

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