Healthcare Provider Details

I. General information

NPI: 1356783906
Provider Name (Legal Business Name): KEITH KAZUTO KOGA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT WAY
BERKELEY CA
94720-4300
US

IV. Provider business mailing address

346 KENILWORTH AVE
SAN LEANDRO CA
94577-1912
US

V. Phone/Fax

Practice location:
  • Phone: 510-642-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number719195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: