Healthcare Provider Details

I. General information

NPI: 1376687772
Provider Name (Legal Business Name): KENICHI T MIYATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3393 G ST D
MERCED CA
95340-0964
US

IV. Provider business mailing address

3393 G ST D
MERCED CA
95340-0964
US

V. Phone/Fax

Practice location:
  • Phone: 209-230-9065
  • Fax: 209-349-8511
Mailing address:
  • Phone: 209-230-3065
  • Fax: 209-349-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA117496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: