Provider Demographics
NPI:1659403228
Name:MEWALDT, KIRSTEN ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:ELIZABETH
Last Name:MEWALDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4650 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6306
Mailing Address - Country:US
Mailing Address - Phone:310-448-5200
Mailing Address - Fax:
Practice Address - Street 1:4650 LINCOLN BLVD
Practice Address - Street 2:UNIT #1604
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6306
Practice Address - Country:US
Practice Address - Phone:626-354-4874
Practice Address - Fax:650-723-0121
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103717207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1037170OtherMEDI-CAL
CACG652ZMedicare PIN