Provider Demographics
NPI:1801816004
Name:RICH, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:RICH
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 1:506 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4014
Mailing Address - Country:US
Mailing Address - Phone:714-374-9111
Mailing Address - Fax:714-374-7311
Practice Address - Street 1:1401 N TUSTIN AVE
Practice Address - Street 2:STE 130
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8644
Practice Address - Country:US
Practice Address - Phone:714-542-3008
Practice Address - Fax:714-542-3617
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50272207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA930128601OtherRAILROAD MEDICARE
CA00A502720Medicaid
CA00A502720Medicaid
CAF21061Medicare UPIN
CAWA50272QMedicare ID - Type Unspecified
CAWA50272PMedicare ID - Type Unspecified