Basic Information
Provider Information | |||||||||
NPI: | 1245468222 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENNETH T SUMIDA MD INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5 HOLLAND STE 101 | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926182568 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9495882190 | ||||||||
FaxNumber: | 9495882199 | ||||||||
Practice Location | |||||||||
Address1: | 1641 CREEKSIDE DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | FOLSOM | ||||||||
State: | CA | ||||||||
PostalCode: | 956303831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9169844242 | ||||||||
FaxNumber: | 9495882199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2009 | ||||||||
LastUpdateDate: | 06/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SUMIDA | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9169844242 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | A67658 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | OOG574130 | 05 | CA |   | MEDICAID |