Provider Demographics
NPI:1316090020
Name:MIYAMURA, ANN (OD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:MIYAMURA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 OLSON DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-5659
Mailing Address - Country:US
Mailing Address - Phone:916-635-1823
Mailing Address - Fax:916-635-0912
Practice Address - Street 1:10921 OLSON DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-5659
Practice Address - Country:US
Practice Address - Phone:916-635-1823
Practice Address - Fax:916-635-0912
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10772T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU65716Medicare UPIN