Basic Information
| Provider Information | |||||||||
| NPI: | 1578568614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIFUNE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DENNIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | |||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952220939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546240 | ||||||||
| FaxNumber: | 8668941902 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952499618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097551400 | ||||||||
| FaxNumber: | 2097551430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G39833 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G398330 | 05 | CA | MEDICAID |