Provider Demographics
NPI:1821081423
Name:TAM, KENNETH K (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:TAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16542 VENTURA BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4562
Mailing Address - Country:US
Mailing Address - Phone:818-782-5041
Mailing Address - Fax:818-205-9091
Practice Address - Street 1:14901 RINALDI ST STE 110
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1253
Practice Address - Country:US
Practice Address - Phone:818-365-1339
Practice Address - Fax:818-898-4301
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG71122207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G71122Medicaid
CAWG71122EMedicare PIN
CA00G71122Medicaid
CAWG71122GMedicare PIN
CAF77641Medicare UPIN
CAWG71122DMedicare PIN
CAWG71122DMedicare PIN
CAWG71122EMedicare PIN
CA00G71122Medicaid
CAWG71122FMedicare PIN