Provider Demographics
NPI:1225334360
Name:KEITH EARL KENYON JR MD INC
Entity Type:Organization
Organization Name:KEITH EARL KENYON JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-2416
Mailing Address - Street 1:201 S ALVARADO ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2320
Mailing Address - Country:US
Mailing Address - Phone:213-483-2416
Mailing Address - Fax:213-483-8211
Practice Address - Street 1:201 S ALVARADO ST
Practice Address - Street 2:SUITE 406
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2320
Practice Address - Country:US
Practice Address - Phone:213-483-2416
Practice Address - Fax:213-483-8211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30715207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G307150Medicaid
CAG30715Medicare PIN
CAA44522Medicare UPIN