Provider Demographics
NPI:1922064161
Name:ISHII, ROY TSUTOMU (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:TSUTOMU
Last Name:ISHII
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:1300 W LODI AVE
Practice Address - Street 2:SUITE P
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3000
Practice Address - Country:US
Practice Address - Phone:209-369-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23529208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A235290Medicaid
CA00A235290Medicaid
CAA23583Medicare UPIN