Provider Demographics
NPI:1508251687
Name:KANAK, MIA MATSUDA (MD, MPH)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:MATSUDA
Last Name:KANAK
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 68TH ST # 179
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:866-463-2778
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST # 179
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:866-463-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-05
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA154810208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics