Provider Demographics
NPI:1689934168
Name:BLUNT, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:BLUNT
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 1:5942 AVENIDA CHAMNEZ
Mailing Address - Street 2:
Mailing Address - City:LAJOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7402
Mailing Address - Country:US
Mailing Address - Phone:858-459-5977
Mailing Address - Fax:858-459-5977
Practice Address - Street 1:5942 AVENIDA CHAMNEZ
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7402
Practice Address - Country:US
Practice Address - Phone:858-459-5977
Practice Address - Fax:858-459-5977
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist