Provider Demographics
NPI:1225370679
Name:EBILANE, KEITH ANDREW KAGAHASTIAN (MD)
Entity Type:Individual
Prefix:
First Name:KEITH ANDREW
Middle Name:KAGAHASTIAN
Last Name:EBILANE
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 1:1212 W REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3411
Mailing Address - Country:US
Mailing Address - Phone:310-225-2825
Mailing Address - Fax:
Practice Address - Street 1:1212 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3411
Practice Address - Country:US
Practice Address - Phone:310-225-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA140101207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine