Provider Demographics
NPI:1144614447
Name:CHANDRASENA, KEVIN SURESH
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:SURESH
Last Name:CHANDRASENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36450 INLAND VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36450 INLAND VALLEY DR
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9583
Practice Address - Country:US
Practice Address - Phone:866-984-7483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125066341207R00000X
CA20A16199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine