Provider Demographics
NPI:1073716874
Name:ISHIMORI, TETSUO (MD)
Entity Type:Individual
Prefix:
First Name:TETSUO
Middle Name:
Last Name:ISHIMORI
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:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1139
Mailing Address - Country:US
Mailing Address - Phone:661-323-8384
Mailing Address - Fax:661-323-9326
Practice Address - Street 1:2901 SILLECT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-6370
Practice Address - Country:US
Practice Address - Phone:661-323-8384
Practice Address - Fax:661-323-9326
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30114207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A301141OtherINDIVIDUAL PTAN
CA060012146OtherRAILROAD MEDICARE
CA953511288OtherTAX ID
CA00A301140Medicare PIN
CA953511288OtherTAX ID