Provider Demographics
NPI:1790880250
Name:THALER, KENNETH S (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:THALER
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 1:14642 NEWPORT AVE
Mailing Address - Street 2:STE 270
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6058
Mailing Address - Country:US
Mailing Address - Phone:714-669-4449
Mailing Address - Fax:
Practice Address - Street 1:14642 NEWPORT AVE
Practice Address - Street 2:STE 270
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6058
Practice Address - Country:US
Practice Address - Phone:714-669-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37603207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G376030Medicaid
CAG37603Medicare PIN
CAA47154Medicare UPIN