Provider Demographics
NPI:1790875276
Name:KIWAN, ELIAS NICOLAS (MD)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:NICOLAS
Last Name:KIWAN
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1020 29TH STREET
Practice Address - Street 2:SUITE 680
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5124
Practice Address - Country:US
Practice Address - Phone:916-453-3300
Practice Address - Fax:916-453-3313
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3479207R00000X, 208M00000X
CAC54469207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150033001Medicaid
H87066Medicare UPIN
AR150033001Medicaid
5M585Medicare PIN