Provider Demographics
NPI:1093703191
Name:KITAGAWA, GENJI C (DO)
Entity Type:Individual
Prefix:DR
First Name:GENJI
Middle Name:C
Last Name:KITAGAWA
Suffix:
Gender:M
Credentials:DO
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 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-944-9644
Practice Address - Street 1:1200 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3354
Practice Address - Country:US
Practice Address - Phone:509-684-3701
Practice Address - Fax:509-684-5817
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001984208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB32999OtherMEDICARE GROUP
WA8433419Medicaid
WAAB32999OtherMEDICARE GROUP
WAG8864459Medicare PIN