Provider Demographics
NPI:1376687772
Name:MIYATA, KENICHI T (MD)
Entity Type:Individual
Prefix:
First Name:KENICHI
Middle Name:T
Last Name:MIYATA
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 1:3393 G ST
Mailing Address - Street 2:D
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0964
Mailing Address - Country:US
Mailing Address - Phone:209-230-3065
Mailing Address - Fax:209-349-8511
Practice Address - Street 1:3393 G ST
Practice Address - Street 2:D
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0964
Practice Address - Country:US
Practice Address - Phone:209-230-9065
Practice Address - Fax:209-349-8511
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117496208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM396AMedicare PIN