Provider Demographics
NPI:1235218074
Name:MARK KUMAMOTO MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:MARK KUMAMOTO MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-883-7243
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1012
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:361 HOSPITAL RD
Practice Address - Street 2:SUITE 124
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3522
Practice Address - Country:US
Practice Address - Phone:949-631-0988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37007207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A370070Medicaid
CA00A370070Medicaid
A28254Medicare UPIN
CAW18714Medicare PIN