Provider Demographics
NPI:1255777934
Name:NAGATOMO, KEI (DO)
Entity type:Individual
Prefix:DR
First Name:KEI
Middle Name:
Last Name:NAGATOMO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16601 N 40TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3356
Mailing Address - Country:US
Mailing Address - Phone:602-996-4747
Mailing Address - Fax:602-953-5466
Practice Address - Street 1:16601 N 40TH ST STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3356
Practice Address - Country:US
Practice Address - Phone:602-996-4747
Practice Address - Fax:602-953-5466
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT015332208600000X
LA324498208600000X
AZ009874208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery