Provider Demographics
NPI:1902106560
Name:NAITO, STACEY KIKUMI (DO)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:KIKUMI
Last Name:NAITO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 BALBOA BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5403
Mailing Address - Country:US
Mailing Address - Phone:818-701-0017
Mailing Address - Fax:818-701-0073
Practice Address - Street 1:9900 BALBOA BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5403
Practice Address - Country:US
Practice Address - Phone:818-701-0017
Practice Address - Fax:818-701-0073
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8154207NS0135X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI20954Medicare UPIN