Provider Demographics
NPI:1346392578
Name:OWEN, KYLE P (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:P
Last Name:OWEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:2213 BUCHANAN RD
Practice Address - Street 2:SUITE 203
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4265
Practice Address - Country:US
Practice Address - Phone:925-779-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A87912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX87910Medicaid
020A87910Medicare ID - Type Unspecified
I17885Medicare UPIN