Provider Demographics
NPI:1184675357
Name:KAN, MICHAEL KC (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KC
Last Name:KAN
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-626-7275
Mailing Address - Fax:858-626-4085
Practice Address - Street 1:9898 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-626-7275
Practice Address - Fax:858-626-4085
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25862207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A258620Medicaid
CA00A258620OtherBLUE SHIELD PIN
CAA24612Medicare UPIN
CAWA25862GMedicare PIN
CA00A258620OtherBLUE SHIELD PIN
CA00A258620Medicaid