Provider Demographics
NPI:1104897610
Name:NAKAYAMA, GLENN SHIGERU (OD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:SHIGERU
Last Name:NAKAYAMA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E HUNTINGTON DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1022
Mailing Address - Country:US
Mailing Address - Phone:626-289-9171
Mailing Address - Fax:626-289-1026
Practice Address - Street 1:100 E HUNTINGTON DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1022
Practice Address - Country:US
Practice Address - Phone:626-289-9171
Practice Address - Fax:626-289-1026
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6521TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0065210Medicaid
CA0209000001Medicare NSC
CA410022583Medicare PIN
T70116Medicare UPIN
CAOP6521Medicare ID - Type Unspecified