Provider Demographics
NPI:1508802992
Name:LIN-HURTUBISE, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:LIN-HURTUBISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:M
Other - Last Name:LIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1400 E CHURCH ST
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-739-3114
Mailing Address - Fax:805-739-3502
Practice Address - Street 1:316 S STRATFORD AVE STE C
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5908
Practice Address - Country:US
Practice Address - Phone:805-348-3700
Practice Address - Fax:805-348-3730
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD11684208600000X
CAG88017208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI501082Medicaid
HIG73713Medicare UPIN