=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215026869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN JAY KANEKO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 12/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 LONG BEACH BLVD
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-5062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-981-6865
-----------------------------------------------------
Fax | 562-595-6471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 E HILL ST
-----------------------------------------------------
City | SIGNAL HILL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90755-3612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-424-6200
-----------------------------------------------------
Fax | 562-427-4634
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A82219
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------