Provider Demographics
NPI:1366453151
Name:MAXWELL, KATHRYN P (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:P
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:P
Other - Last Name:NEMANICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 FIR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2327
Mailing Address - Country:US
Mailing Address - Phone:858-499-2777
Mailing Address - Fax:
Practice Address - Street 1:300 FIR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2327
Practice Address - Country:US
Practice Address - Phone:858-499-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85871207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI37197Medicare UPIN
CAWA85871AMedicare ID - Type Unspecified