Provider Demographics
NPI:1558309377
Name:MCCAFFREY, KENNETH G (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:MCCAFFREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4551 GLENCOE AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6385
Mailing Address - Country:US
Mailing Address - Phone:310-301-2030
Mailing Address - Fax:310-306-5247
Practice Address - Street 1:2400 E 4TH ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2026
Practice Address - Country:US
Practice Address - Phone:619-470-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52216207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
930073893OtherRAILROAD MEDICARE
CA00G522160Medicaid
G52216OtherBC OF CA
00G522160Medicare PIN
G52216OtherBC OF CA
CA00G522160Medicaid