Provider Demographics
NPI:1689778128
Name:IRIE, KENJI (MD)
Entity Type:Individual
Prefix:
First Name:KENJI
Middle Name:
Last Name:IRIE
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 1:420 E THIRD ST
Mailing Address - Street 2:SUITE 903
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013
Mailing Address - Country:US
Mailing Address - Phone:213-617-0266
Mailing Address - Fax:213-617-7332
Practice Address - Street 1:420 E THIRD ST
Practice Address - Street 2:SUITE 903
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013
Practice Address - Country:US
Practice Address - Phone:213-617-0266
Practice Address - Fax:213-617-7332
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30886208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A26270Medicare UPIN
CAA30886Medicare ID - Type Unspecified