Provider Demographics
NPI:1679623722
Name:HA, JEFFREY K (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:K
Last Name:HA
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 1:1320 NORTHSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1120
Mailing Address - Country:US
Mailing Address - Phone:510-508-6284
Mailing Address - Fax:
Practice Address - Street 1:500 SOUTHLAND MALL
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2148
Practice Address - Country:US
Practice Address - Phone:510-887-2800
Practice Address - Fax:510-887-2812
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0125790Medicare ID - Type Unspecified
CAV01753Medicare UPIN