Provider Demographics
NPI:1114020500
Name:LUO, KENYON S (MD)
Entity Type:Individual
Prefix:DR
First Name:KENYON
Middle Name:S
Last Name:LUO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4418 VINELAND AVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2159
Mailing Address - Country:US
Mailing Address - Phone:818-769-0995
Mailing Address - Fax:818-762-0988
Practice Address - Street 1:4418 VINELAND AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-2159
Practice Address - Country:US
Practice Address - Phone:818-769-0995
Practice Address - Fax:818-762-0988
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33917207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33917Medicaid
CAA33917Medicaid
A88006Medicare UPIN