Provider Demographics
NPI:1417984931
Name:RAEBER, KIRK JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:JOHN
Last Name:RAEBER
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:PO BOX 1104
Mailing Address - Street 2:
Mailing Address - City:JAMUL
Mailing Address - State:CA
Mailing Address - Zip Code:91935-1104
Mailing Address - Country:US
Mailing Address - Phone:619-468-3119
Mailing Address - Fax:
Practice Address - Street 1:435 H ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4307
Practice Address - Country:US
Practice Address - Phone:619-691-7290
Practice Address - Fax:619-691-7432
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4463207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX44630Medicaid
CAB58244Medicare UPIN
W20A4463AMedicare PIN
CA00AX44630Medicaid