Provider Demographics
NPI:1598108045
Name:KENICHI T. MIYATA MD INC
Entity Type:Organization
Organization Name:KENICHI T. MIYATA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:KENICHI
Authorized Official - Middle Name:T
Authorized Official - Last Name:MIYATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-580-4866
Mailing Address - Street 1:700 W OLIVE AVE STE F
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2435
Mailing Address - Country:US
Mailing Address - Phone:209-580-4866
Mailing Address - Fax:209-580-4861
Practice Address - Street 1:700 W OLIVE AVE STE F
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2435
Practice Address - Country:US
Practice Address - Phone:209-580-4866
Practice Address - Fax:209-580-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117496208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA117496OtherMEDICAL LICENSE