Provider Demographics
NPI:1790976637
Name:DEWALT, KEVIN CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHRISTOPHER
Last Name:DEWALT
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 1:108 GRANADA DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-4556
Mailing Address - Country:US
Mailing Address - Phone:650-796-2113
Mailing Address - Fax:
Practice Address - Street 1:108 GRANADA DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-4556
Practice Address - Country:US
Practice Address - Phone:650-796-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92755282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital