Provider Demographics
NPI:1770632234
Name:ORANGE COUNTY GASTROENTEROLOGICAL MEDICAL GROUP INCORPORATED
Entity Type:Organization
Organization Name:ORANGE COUNTY GASTROENTEROLOGICAL MEDICAL GROUP INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:YAMASHIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-995-4704
Mailing Address - Street 1:3055 W ORANGE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3152
Mailing Address - Country:US
Mailing Address - Phone:714-995-4704
Mailing Address - Fax:714-995-3814
Practice Address - Street 1:3055 W ORANGE AVE STE 105
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3152
Practice Address - Country:US
Practice Address - Phone:714-995-4704
Practice Address - Fax:714-995-3814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13929207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1843815Medicaid
CA1843815Medicaid
CAW2813Medicare ID - Type Unspecified