Provider Demographics
NPI:1679560973
Name:KODAMA, CURTIS KIYOSHI (DO)
Entity type:Individual
Prefix:DR
First Name:CURTIS
Middle Name:KIYOSHI
Last Name:KODAMA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 PATRIOT DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3407
Mailing Address - Country:US
Mailing Address - Phone:805-532-2032
Mailing Address - Fax:805-532-2844
Practice Address - Street 1:865 PATRIOT DR STE 101
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3407
Practice Address - Country:US
Practice Address - Phone:805-532-2032
Practice Address - Fax:805-532-2844
Is Sole Proprietor?:No
Enumeration Date:2005-10-01
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX61430Medicaid
CAW20A6143GMedicare ID - Type Unspecified
CA00AX61430Medicaid