Provider Demographics
NPI:1578559084
Name:KINTNER, PHILLIP LEE (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LEE
Last Name:KINTNER
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 SIERRA COLLEGE DR STE 115
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5763
Practice Address - Country:US
Practice Address - Phone:530-477-3119
Practice Address - Fax:530-274-2077
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88574207V00000X, 207V00000X
IL036-076059207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076059Medicaid
IL036076059Medicaid
ILE18643Medicare UPIN