Healthcare Provider Details

I. General information

NPI: 1962450296
Provider Name (Legal Business Name): KENNETH HIROSHI KANESHIRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 TEMPLE ST
MASON MI
48854-1837
US

IV. Provider business mailing address

230 TEMPLE ST PO BOX 39
MASON MI
48854-1837
US

V. Phone/Fax

Practice location:
  • Phone: 517-676-9066
  • Fax: 517-676-3505
Mailing address:
  • Phone: 517-676-9066
  • Fax: 517-676-3505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4301050328
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: