Provider Demographics
NPI:1053429027
Name:SHIMOZAKI, KENNETH K (DPM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:SHIMOZAKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W MARCH LN
Mailing Address - Street 2:SUITE 310
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-6500
Mailing Address - Country:US
Mailing Address - Phone:209-472-0800
Mailing Address - Fax:209-472-1203
Practice Address - Street 1:3031 W MARCH LN
Practice Address - Street 2:SUITE 310
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-6500
Practice Address - Country:US
Practice Address - Phone:209-472-0800
Practice Address - Fax:209-472-1203
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3847213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001670Medicaid
CAE3847OtherSTATE LICENSE #
CAE3847OtherSTATE LICENSE #
CAE3847OtherSTATE LICENSE #
CAU36947Medicare UPIN
CAZZZ25747ZMedicare ID - Type UnspecifiedGROUP MEDICARE #