Provider Demographics
NPI:1285633784
Name:NAKAMOTO, STANLEY KAZUO (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:KAZUO
Last Name:NAKAMOTO
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 14005
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-1405
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:431 S BATAVIA ST
Practice Address - Street 2:STE. 103
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3936
Practice Address - Country:US
Practice Address - Phone:714-538-6731
Practice Address - Fax:714-771-8369
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG432642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G432640 159OtherCALOPTIMA
300035984OtherRAILROAD MEDICARE
00G432640OtherBLUE SHIELD OF CA
053304CA49292OtherTRAILBLAZER
CA00G432640Medicaid
300035984OtherRAILROAD MEDICARE
WG43264AMedicare PIN
WG43264CMedicare PIN
00G432640 159OtherCALOPTIMA
A49292Medicare UPIN