Healthcare Provider Details

I. General information

NPI: 1194704387
Provider Name (Legal Business Name): MICHIO KAJITANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E HIGHLAND AVE STE 251
SAN BERNARDINO CA
92404-3800
US

IV. Provider business mailing address

3400 DATA DR ATTN: CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 909-882-4605
  • Fax: 909-475-2680
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberE-2437
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA89049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: