Provider Demographics
NPI:1831109982
Name:KETTLEHAKE, PATRICIA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:KETTLEHAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 PROSPECT PL
Mailing Address - Street 2:STE 220
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1978
Mailing Address - Country:US
Mailing Address - Phone:619-435-2670
Mailing Address - Fax:
Practice Address - Street 1:230 PROSPECT PL
Practice Address - Street 2:STE 220
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1978
Practice Address - Country:US
Practice Address - Phone:619-435-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68312207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A683120Medicaid
CAA68312Medicare ID - Type Unspecified
CA00A683120Medicaid