Provider Demographics
NPI:1700814902
Name:SUGIMOTO, BRIAN KENJI (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KENJI
Last Name:SUGIMOTO
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:PO BOX 3768
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-3768
Mailing Address - Country:US
Mailing Address - Phone:209-723-3704
Mailing Address - Fax:209-723-0272
Practice Address - Street 1:3393 G ST STE C
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-1001
Practice Address - Country:US
Practice Address - Phone:209-580-4172
Practice Address - Fax:209-233-9859
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80308207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G803080Medicaid
CA00G803080Medicare PIN
CA00G803083Medicare PIN
CAG23642Medicare UPIN