Provider Demographics
NPI:1245468222
Name:KENNETH T SUMIDA MD INC
Entity type:Organization
Organization Name:KENNETH T SUMIDA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:SUMIDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-984-4242
Mailing Address - Street 1:5 HOLLAND STE 101
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2568
Mailing Address - Country:US
Mailing Address - Phone:949-588-2190
Mailing Address - Fax:949-588-2199
Practice Address - Street 1:1641 CREEKSIDE DR STE 100
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3831
Practice Address - Country:US
Practice Address - Phone:916-984-4242
Practice Address - Fax:949-588-2199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67658208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG574130Medicaid