Provider Demographics
NPI:1861470783
Name:SMALL, KENT W (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:W
Last Name:SMALL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:501 NORTH ORANGE STREET
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1971
Mailing Address - Country:US
Mailing Address - Phone:818-552-5040
Mailing Address - Fax:818-552-5044
Practice Address - Street 1:411 N CENTRAL AVE STE 115
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-3138
Practice Address - Country:US
Practice Address - Phone:818-552-5040
Practice Address - Fax:818-552-5044
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA53173207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75843ZMedicaid
CAZZZ75843ZMedicaid
CAW18127FMedicare UPIN