Provider Demographics
NPI:1881606309
Name:KURISU, WAYNE OWEN (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:OWEN
Last Name:KURISU
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 1:300 FIR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2327
Mailing Address - Country:US
Mailing Address - Phone:858-499-2703
Mailing Address - Fax:619-446-1742
Practice Address - Street 1:300 FIR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2327
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-446-1569
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64273207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A642730Medicaid
CAH31406Medicare UPIN
CAWA64273AMedicare ID - Type Unspecified