Provider Demographics
NPI:1306835012
Name:SATO, KEN SODERLUND (MD)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:SODERLUND
Last Name:SATO
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 1:849 ALMAR AVE
Mailing Address - Street 2:SUITE C, #169
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5875
Mailing Address - Country:US
Mailing Address - Phone:831-401-2313
Mailing Address - Fax:
Practice Address - Street 1:352 ALTA AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-6442
Practice Address - Country:US
Practice Address - Phone:831-401-2313
Practice Address - Fax:831-401-2313
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85728207T00000X
ORMD24401207T00000X
HI10583207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297482Medicaid
CA00G857280Medicaid
CAG857280Medicare UPIN
CA00G857280Medicare ID - Type Unspecified
OR297482Medicaid
ORG97955Medicare UPIN
OR119222Medicare ID - Type Unspecified