Provider Demographics
NPI:1568405405
Name:KISHIYAMA, KAYNE K (MD)
Entity Type:Individual
Prefix:MR
First Name:KAYNE
Middle Name:K
Last Name:KISHIYAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1498 MIDWAY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4587
Mailing Address - Country:US
Mailing Address - Phone:208-552-0920
Mailing Address - Fax:208-529-2564
Practice Address - Street 1:1498 MIDWAY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4587
Practice Address - Country:US
Practice Address - Phone:208-552-0920
Practice Address - Fax:208-529-2564
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-66382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804042400Medicaid
ID11308831Medicare UPIN
IDF45665Medicare UPIN
ID1130884Medicare ID - Type Unspecified