MEDICARE: DR. WAYNE OGATA O.D. INC.

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	9705T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9705T	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1902840796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. WAYNE OGATA O.D. INC.

Provider Business Mailing Address
First Line	:	4300 SONOMA BLVD
Second Line	:	#508
City	:	VALLEJO
State	:	CA
Zip	:	94589-2200
Country	:	US
Telephone Number	:	707-643-8891
Fax Number	:	707-644-8649

Provider Business Practice Location Address
First Line	:	4300 SONOMA BLVD
Second Line	:	#508
City	:	VALLEJO
State	:	CA
Zip	:	94589-2200
Country	:	US
Telephone Number	:	707-643-8891
Fax Number	:	707-644-8649

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WAYNE KANEO OGATA
Credential	:	O.D.
Telephone Number	:	707-643-8891

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	08/06/2010

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