Healthcare Provider Details

I. General information

NPI: 1508183765
Provider Name (Legal Business Name): YASUKO KIDOKORO MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4282 GENESEE AVE SUITE 202
SAN DIEGO CA
92117-4946
US

IV. Provider business mailing address

4282 GENESEE AVE SUITE 202
SAN DIEGO CA
92117-4946
US

V. Phone/Fax

Practice location:
  • Phone: 858-277-9669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA032727
License Number StateCA

VIII. Authorized Official

Name: YASUKO KIDOKORO
Title or Position: MD
Credential: MD
Phone: 858-277-9669