Mark Shigeo Komure, O.D.

Primary specialty

OptometristTaxonomy code 152W00000X

License

6480T Issued in CA

Practice address

2087 Grand Canal Blvd Ste 15
Stockton, CA 95207-6651

Phone

(209) 477-0296

Fax

(209) 478-7322

NPI assigned

Mar 14, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CA2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 2

Specialty

Optometry

Education

Southern California College of Optometry, 1978

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173830400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1254441600000",
    "number": "1689707713",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2087 GRAND CANAL BLVD STE 15",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952076651",
            "telephone_number": "209-477-0296",
            "fax_number": "209-478-7322"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2087 GRAND CANAL BLVD STE 15",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952076651",
            "telephone_number": "209-477-0296",
            "fax_number": "209-478-7322"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KOMURE",
        "first_name": "MARK",
        "middle_name": "SHIGEO",
        "name_prefix": "Dr.",
        "credential": "O.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-03-14",
        "last_updated": "2009-10-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "CA",
            "license": "6480T",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1930714",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Thomas Koesterer, PH.D., ATC
• Carolynn Kohn, PHD, BCBA-D
• Michelle Acojido Koide, PHARM. D
• Suzanna Kolodrivskiy
• Somboon Kom
• Carol Kong, LCSW
• May Kong
• Saorath Kong
• Jajin Koo
• Susan T Koo, MD

• Optometrist in Stockton, CA
• Providers in Stockton, CA by specialty
• Optometrist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.