Provider Demographics
NPI:1043417447
Name:KENYON, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:KENYON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17081 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4219
Mailing Address - Country:US
Mailing Address - Phone:714-846-4913
Mailing Address - Fax:
Practice Address - Street 1:411 N LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-3028
Practice Address - Country:US
Practice Address - Phone:714-279-5449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23234207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology