Provider Demographics
NPI:1639178692
Name:KAVALICH, ALLAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:G
Last Name:KAVALICH
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 1:1500 N WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5111
Mailing Address - Country:US
Mailing Address - Phone:909-381-1595
Mailing Address - Fax:909-381-3291
Practice Address - Street 1:1500 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5111
Practice Address - Country:US
Practice Address - Phone:909-381-1595
Practice Address - Fax:909-381-3291
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29326207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G293260Medicaid
CA00G293260Medicare ID - Type Unspecified
CA00G293260Medicaid