Provider Demographics
NPI:1649614819
Name:YAMAGUCHI, KENT TAKAO JR (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:TAKAO
Last Name:YAMAGUCHI
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KENT
Other - Middle Name:TAKAO
Other - Last Name:YAMAGUCHI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:76-143 CHS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-6902
Mailing Address - Country:US
Mailing Address - Phone:310-825-6557
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:76-143 CHS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6902
Practice Address - Country:US
Practice Address - Phone:310-825-6557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA133598207X00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program