Provider Demographics
NPI:1578749685
Name:SALL, KENNETH NEIL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:NEIL
Last Name:SALL
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 1:11423 187TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-5653
Mailing Address - Country:US
Mailing Address - Phone:562-804-1974
Mailing Address - Fax:562-804-4350
Practice Address - Street 1:11423 187TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-5653
Practice Address - Country:US
Practice Address - Phone:562-804-1974
Practice Address - Fax:562-804-4350
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44902207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G449020Medicaid
CABA666Medicare PIN
CA00G449020Medicaid