Provider Demographics
NPI:1417007014
Name:KISHIMOTO, MICHELLE R (OD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:KISHIMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17868 HAZELWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-7481
Mailing Address - Country:US
Mailing Address - Phone:310-886-0346
Mailing Address - Fax:
Practice Address - Street 1:1815 HAWTHORNE BLVD
Practice Address - Street 2:STE 236 GALLERIA AT SOUTH BAY
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3424
Practice Address - Country:US
Practice Address - Phone:310-370-1618
Practice Address - Fax:310-371-3126
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11949T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU92696Medicare UPIN
CAWOP11949Medicare ID - Type Unspecified