Provider Demographics
NPI:1669691374
Name:KENNETH P. JIANG MD, INC
Entity type:Organization
Organization Name:KENNETH P. JIANG MD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:SEIJI
Authorized Official - Last Name:KUSUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, PA
Authorized Official - Phone:831-636-3116
Mailing Address - Street 1:1760 F AIRLINE HWY #193
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023
Mailing Address - Country:US
Mailing Address - Phone:831-636-1204
Mailing Address - Fax:
Practice Address - Street 1:890 SUNSET DR.
Practice Address - Street 2:SUITE A-2
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023
Practice Address - Country:US
Practice Address - Phone:831-636-3116
Practice Address - Fax:831-636-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66628207R00000X
CAA65656207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21790ZMedicare ID - Type Unspecified