Healthcare Provider Details

I. General information

NPI: 1619467628
Provider Name (Legal Business Name): CHARLENE V. KAKIMOTO, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 PROSPECT PL STE 260
CORONADO CA
92118-1987
US

IV. Provider business mailing address

230 PROSPECT PL STE 260
CORONADO CA
92118-1987
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-1146
  • Fax:
Mailing address:
  • Phone: 619-437-1146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: SIRENA FERGUSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 619-437-1146