Provider Demographics
NPI:1396892972
Name:MASATSUGU, MILES KEN (MD)
Entity type:Individual
Prefix:DR
First Name:MILES
Middle Name:KEN
Last Name:MASATSUGU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3378 CORTE CASSIS
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1667
Mailing Address - Country:US
Mailing Address - Phone:626-347-0232
Mailing Address - Fax:
Practice Address - Street 1:420 S GLENDORA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3001
Practice Address - Country:US
Practice Address - Phone:626-919-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA070325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA070325Medicaid
CAH54497Medicare UPIN