Provider Demographics
NPI:1225119209
Name:KIYOMOTO, MICHAEL G (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:KIYOMOTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1613
Mailing Address - Country:US
Mailing Address - Phone:510-843-0721
Mailing Address - Fax:510-843-0721
Practice Address - Street 1:2035 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1613
Practice Address - Country:US
Practice Address - Phone:510-843-0721
Practice Address - Fax:510-843-0721
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7506TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0075060Medicaid
CASD0075060Medicaid
CASD0075060Medicare ID - Type Unspecified
CA0209310001Medicare NSC