Provider Demographics
NPI:1124130901
Name:KIDOKORO, YASUKO (MD)
Entity type:Individual
Prefix:DR
First Name:YASUKO
Middle Name:
Last Name:KIDOKORO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5222 BALBOA AVE STE 31
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6952
Mailing Address - Country:US
Mailing Address - Phone:858-277-9669
Mailing Address - Fax:858-277-9901
Practice Address - Street 1:5222 BALBOA AVE STE 31
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6952
Practice Address - Country:US
Practice Address - Phone:858-277-9669
Practice Address - Fax:858-277-9901
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA032727207QA0505X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A26909Medicare ID - Type Unspecified
A26909Medicare UPIN