Healthcare Provider Details

I. General information

NPI: 1740415785
Provider Name (Legal Business Name): MIO KITANO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7979 WURZBACH RD 6TH FLOOR, ZELLER BLDG
SAN ANTONIO TX
78229-4427
US

IV. Provider business mailing address

7703 FLOYD CURL DR
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-5990
  • Fax: 210-450-1747
Mailing address:
  • Phone: 210-450-5990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number51796020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberQ9655
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: