Provider Demographics
NPI:1073744546
Name:KUBOMOTO, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:KUBOMOTO
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 1:11100 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3384
Mailing Address - Country:US
Mailing Address - Phone:424-321-6309
Mailing Address - Fax:
Practice Address - Street 1:11100 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3384
Practice Address - Country:US
Practice Address - Phone:424-321-6309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-01
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115254208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine