Provider Demographics
NPI:1902855588
Name:KERRY B EVNIN MD INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KERRY B EVNIN MD INC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVNIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-531-0154
Mailing Address - Street 1:3641 MITCHELL RD
Mailing Address - Street 2:H
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307
Mailing Address - Country:US
Mailing Address - Phone:209-531-0154
Mailing Address - Fax:209-531-0176
Practice Address - Street 1:3641 MITCHELL RD
Practice Address - Street 2:H
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307
Practice Address - Country:US
Practice Address - Phone:209-531-0154
Practice Address - Fax:209-531-0176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA655240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A52907Medicare UPIN