Provider Demographics
NPI:1528273570
Name:MIDORI NISHIMURA M D IBCLC FAMILY MEDICINE AND LACTATION INC
Entity type:Organization
Organization Name:MIDORI NISHIMURA M D IBCLC FAMILY MEDICINE AND LACTATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:PONTERIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-341-6240
Mailing Address - Street 1:1704 MIRAMONTE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-3766
Mailing Address - Country:US
Mailing Address - Phone:650-996-1943
Mailing Address - Fax:408-283-2563
Practice Address - Street 1:1704 MIRAMONTE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3766
Practice Address - Country:US
Practice Address - Phone:650-996-1943
Practice Address - Fax:408-283-2563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-12
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG84817Medicare UPIN