Provider Demographics
NPI:1629089529
Name:GRABOW, KENNETH R (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:GRABOW
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 1:1200 N TUSTIN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3508
Mailing Address - Country:US
Mailing Address - Phone:714-542-5999
Mailing Address - Fax:
Practice Address - Street 1:1200 N TUSTIN AVE
Practice Address - Street 2:STE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3508
Practice Address - Country:US
Practice Address - Phone:714-542-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66481207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA183774600OtherDEPT OF LABOR
CAG66481Medicaid
CAG66481Medicare ID - Type Unspecified
CAG66481Medicaid