Provider Demographics
NPI:1871550574
Name:KAGEYAMA, DAVID T (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:KAGEYAMA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9401 E STOCKTON BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624
Mailing Address - Country:US
Mailing Address - Phone:916-686-4937
Mailing Address - Fax:916-686-4469
Practice Address - Street 1:9401 E STOCKTON BLVD
Practice Address - Street 2:STE 105
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624
Practice Address - Country:US
Practice Address - Phone:916-686-4937
Practice Address - Fax:916-686-4469
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GZ604ZOtherMEDICARE PTAN
CA0433340001OtherSUPPLIER #
T95659Medicare UPIN
CA0433340001OtherSUPPLIER #