Provider Demographics
NPI:1871578161
Name:KUMAMOTO, GRACE NOZOMI (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:NOZOMI
Last Name:KUMAMOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-697-5473
Mailing Address - Fax:951-697-5513
Practice Address - Street 1:6405 DAY ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0901
Practice Address - Country:US
Practice Address - Phone:951-697-5473
Practice Address - Fax:951-697-5513
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ92058ZOtherGROUP SITE LOCATION
G91471Medicare UPIN
ZZZ92058ZOtherGROUP SITE LOCATION