Provider Demographics
NPI:1518994581
Name:ISHIZUE, KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:ISHIZUE
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 1:1441 CONSTITUTION BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-3127
Mailing Address - Country:US
Mailing Address - Phone:831-755-4111
Mailing Address - Fax:831-759-6565
Practice Address - Street 1:1441 CONSTITUTION BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3127
Practice Address - Country:US
Practice Address - Phone:831-755-4111
Practice Address - Fax:831-759-6565
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56343207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G563430Medicaid
CAF33668Medicare UPIN
CA00G563431Medicare PIN