Provider Demographics
NPI:1467545368
Name:YAMAMOTO, KENNETH SUSUMU (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SUSUMU
Last Name:YAMAMOTO
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 1:1800 SULLIVAN AVE
Mailing Address - Street 2:SUITE 603
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2225
Mailing Address - Country:US
Mailing Address - Phone:415-337-2121
Mailing Address - Fax:415-337-1247
Practice Address - Street 1:1800 SULLIVAN AVE
Practice Address - Street 2:SUITE 603
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2225
Practice Address - Country:US
Practice Address - Phone:415-337-2121
Practice Address - Fax:415-337-1247
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31340207R00000X, 207RX0202X
CAG313400207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G313400Medicaid
A44729Medicare UPIN
CA00G313402Medicare PIN