Provider Demographics
NPI:1962450296
Name:KANESHIRO, KENNETH HIROSHI (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:HIROSHI
Last Name:KANESHIRO
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 1:230 TEMPLE ST
Mailing Address - Street 2:PO BOX 39
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-1837
Mailing Address - Country:US
Mailing Address - Phone:517-676-9066
Mailing Address - Fax:517-676-3505
Practice Address - Street 1:230 TEMPLE ST
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-1837
Practice Address - Country:US
Practice Address - Phone:517-676-9066
Practice Address - Fax:517-676-3505
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050328207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01-00217OtherPHPMM
MIKK050328OtherBCBS
MIP94722OtherBCN
MI0170217OtherPHPFC
MIKK050328OtherBCBS
MIOC34715006Medicare ID - Type Unspecified