Provider Demographics
NPI:1275501496
Name:HUNTSMAN, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HUNTSMAN
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 1:1310 W STEWART DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3854
Mailing Address - Country:US
Mailing Address - Phone:714-639-9401
Mailing Address - Fax:714-639-7095
Practice Address - Street 1:1310 W STEWART DR
Practice Address - Street 2:SUITE 410
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3854
Practice Address - Country:US
Practice Address - Phone:714-639-9401
Practice Address - Fax:714-639-7095
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34408208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110200069OtherRAIL ROAD MEDICARE - PROVIDER PTAN
CAW1514OtherMEDICARE PTAN - TYPE 2
CACG5665OtherRAIL ROAD MEDICARE - GROUP PTAN
CA1912919804OtherNPI - TYPE 2
CAF01155Medicare UPIN
CA110200069OtherRAIL ROAD MEDICARE - PROVIDER PTAN