Basic Information
| Provider Information | |||||||||
| NPI: | 1124297395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATSUMI | ||||||||
| FirstName: | HIROSHI | ||||||||
| MiddleName: | KAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | PHR GROUP PROVIDER ENROLLMENT UNIT, 3RD FL | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | 8775140903 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 THE CITY DR S | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144566357 | ||||||||
| FaxNumber: | 7144565342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A93331 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | GR0085140 | 05 | CA | MEDICAID | W14887 | 01 | CA | MEDICARE GROUP | OTHER | W457 | 01 | CA | PALMETTO GROUP PTAN | OTHER | ZZZ54082Z | 01 | CA | BLUE SHIELD | OTHER |