Provider Demographics
NPI:1184837098
Name:TESHIMA, KENNETH MEGUMI (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MEGUMI
Last Name:TESHIMA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24331 EL TORO ROAD, SUITE 370
Mailing Address - Street 2:
Mailing Address - City:LAGUNA WOODS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-3104
Mailing Address - Country:US
Mailing Address - Phone:949-951-9207
Mailing Address - Fax:949-588-8826
Practice Address - Street 1:24331 EL TORO ROAD, SUITE 370
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-3104
Practice Address - Country:US
Practice Address - Phone:949-951-9207
Practice Address - Fax:949-588-8826
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2103213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000021929OtherMEDICARE EDI #
CA000E21030Medicaid
CAT11177Medicare UPIN
CA000E21030Medicaid