Provider Demographics
NPI:1164681896
Name:ISHIMOTO, GREGORY SHOICHI (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SHOICHI
Last Name:ISHIMOTO
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 1:4100 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5497
Mailing Address - Country:US
Mailing Address - Phone:805-624-0615
Mailing Address - Fax:
Practice Address - Street 1:4100 DEWEY ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5497
Practice Address - Country:US
Practice Address - Phone:805-624-0615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI56106-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program