Basic Information
Provider Information | |||||||||
NPI: | 1831317684 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOBAYASHI | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | SHOU | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1801 E MARCH LN | ||||||||
Address2: | SUITE A130 | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952106629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094759871 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1801 E MARCH LN | ||||||||
Address2: | SUITE A130 | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952106629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094759871 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2007 | ||||||||
LastUpdateDate: | 07/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A99348 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.