1619935079 NPI number — DR. WALTER TAKESHI KUSUMOTO M.D. M.P.H.

Table of content: DR. WALTER TAKESHI KUSUMOTO M.D. M.P.H. (NPI 1619935079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619935079 NPI number — DR. WALTER TAKESHI KUSUMOTO M.D. M.P.H.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUSUMOTO
Provider First Name:
WALTER
Provider Middle Name:
TAKESHI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D. M.P.H.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KUSUMOTO
Provider Other First Name:
WALTER
Provider Other Middle Name:
T.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D. M.P.H.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1619935079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1645 ESPLANADE STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95926-3367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-893-8806
Provider Business Mailing Address Fax Number:
530-893-8846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1645 ESPLANADE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CHICO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95926-3367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-893-8806
Provider Business Practice Location Address Fax Number:
530-893-8846
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  A60788 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: A60788 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A60788 . This is a "MEDICAL BOARD OF CALIFORNIA - CALIFORNIA MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1619935079 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00A607880 . This is a "CENTERS FOR MEDICARE & MEDICADE SERVICES (CMS): MEDICARE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A607880 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BK5138169 . This is a "DEA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FNP 41401 . This is a "MEDICAL BOARD OF CALIFORNIA--FICTICIOUS NAME PERMIT (FNP)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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