Provider Demographics
NPI:1386637528
Name:KENYON, KEITH E JR (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:KENYON
Suffix:JR
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 1:201 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
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30715207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G307150Medicaid
A44522Medicare UPIN
CAG30715Medicare ID - Type Unspecified