Provider Demographics
NPI:1689616278
Name:KINNAN, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:KINNAN
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:PO BOX 969096
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92196-9096
Mailing Address - Country:US
Mailing Address - Phone:858-495-0971
Mailing Address - Fax:
Practice Address - Street 1:1415 ROSS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4306
Practice Address - Country:US
Practice Address - Phone:760-339-7100
Practice Address - Fax:760-339-7389
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22729207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22729AMedicare PIN
A82675Medicare UPIN