Provider Demographics
NPI:1194814152
Name:MIYAMOTO, KEITH S (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:S
Last Name:MIYAMOTO
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 1277
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90609-1277
Mailing Address - Country:US
Mailing Address - Phone:562-906-6470
Mailing Address - Fax:562-946-9465
Practice Address - Street 1:15725 E WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-2347
Practice Address - Country:US
Practice Address - Phone:562-947-8478
Practice Address - Fax:562-947-2238
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56322208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG56322CMedicare ID - Type Unspecified
CAE64347Medicare UPIN