Provider Demographics
NPI:1043283997
Name:HALLOWS, KENNETH R (PHD,MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:HALLOWS
Suffix:
Gender:M
Credentials:PHD,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 ZONAL AVE # IRD806
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0121
Mailing Address - Country:US
Mailing Address - Phone:323-442-1040
Mailing Address - Fax:
Practice Address - Street 1:2020 ZONAL AVE # IRD806
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0121
Practice Address - Country:US
Practice Address - Phone:323-442-1040
Practice Address - Fax:323-442-2881
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062123L174400000X
CAC136632207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001861031Medicaid
PA051345DYLMedicare ID - Type Unspecified