Provider Demographics
NPI:1063610210
Name:KENNETH ISHIZUE MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:KENNETH ISHIZUE MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:ISHIZUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-755-4299
Mailing Address - Street 1:12705 CORTE CORDILLERA
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93908-8942
Mailing Address - Country:US
Mailing Address - Phone:831-755-4299
Mailing Address - Fax:
Practice Address - Street 1:1441 CONSTITUTION BLVD
Practice Address - Street 2:SUITE 200 ORTHOPEDICS CLINIC
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3100
Practice Address - Country:US
Practice Address - Phone:831-755-4299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56343207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G56340Medicare PIN