Healthcare Provider Details

I. General information

NPI: 1215026869
Provider Name (Legal Business Name): RYAN JAY KANEKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 LONG BEACH BLVD
LONG BEACH CA
90807-5062
US

IV. Provider business mailing address

1600 E HILL ST
SIGNAL HILL CA
90755-3612
US

V. Phone/Fax

Practice location:
  • Phone: 562-981-6865
  • Fax: 562-595-6471
Mailing address:
  • Phone: 562-424-6200
  • Fax: 562-427-4634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA82219
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: