Provider Demographics
NPI:1437424090
Name:WALTZER, KENNETH BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRIAN
Last Name:WALTZER
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 1:171 PIER AVE # 160
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-5311
Mailing Address - Country:US
Mailing Address - Phone:424-228-2421
Mailing Address - Fax:
Practice Address - Street 1:171 PIER AVE # 160
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-5311
Practice Address - Country:US
Practice Address - Phone:424-228-2421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45950207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA14228Medicare UPIN