Provider Demographics
NPI:1619935079
Name:KUSUMOTO, WALTER TAKESHI (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:TAKESHI
Last Name:KUSUMOTO
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:DR
Other - First Name:WALTER
Other - Middle Name:T
Other - Last Name:KUSUMOTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD MPH
Mailing Address - Street 1:1645 ESPLANADE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3367
Mailing Address - Country:US
Mailing Address - Phone:530-893-8806
Mailing Address - Fax:530-893-8846
Practice Address - Street 1:1645 ESPLANADE
Practice Address - Street 2:SUITE 3
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3367
Practice Address - Country:US
Practice Address - Phone:530-893-8806
Practice Address - Fax:530-893-8846
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60788207RI0011X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA60788OtherMEDICAL BOARD OF CALIFORNIA - CALIFORNIA MEDICAL LICENSE
1619935079OtherNPI
CA00A607880OtherCENTERS FOR MEDICARE & MEDICADE SERVICES (CMS): MEDICARE ID
CA00A607880OtherMEDI-CAL
CABK5138169OtherDEA
CAFNP 41401OtherMEDICAL BOARD OF CALIFORNIA--FICTICIOUS NAME PERMIT (FNP)
CA00A607880OtherMEDI-CAL
CAFNP 41401OtherMEDICAL BOARD OF CALIFORNIA--FICTICIOUS NAME PERMIT (FNP)