Provider Demographics
NPI:1962421958
Name:KIMURA, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:KIMURA
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 1:3460 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2334
Mailing Address - Country:US
Mailing Address - Phone:562-594-6599
Mailing Address - Fax:562-598-6220
Practice Address - Street 1:3460 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2334
Practice Address - Country:US
Practice Address - Phone:562-594-6599
Practice Address - Fax:562-598-6220
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG56213AMedicare PIN
W11720Medicare PIN