Provider Demographics
NPI:1790921294
Name:ANDERSON, KENNETH WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:ANDERSON
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 1:50 N LA CIENEGA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2227
Mailing Address - Country:US
Mailing Address - Phone:310-985-3104
Mailing Address - Fax:
Practice Address - Street 1:50 N LA CIENEGA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2227
Practice Address - Country:US
Practice Address - Phone:310-985-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57040207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery