Provider Demographics
NPI:1962511162
Name:HOWALT, KRISTOPHER DANE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:DANE
Last Name:HOWALT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:K
Other - Middle Name:DANE
Other - Last Name:HAWALT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7246 REMMET AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1531
Mailing Address - Country:US
Mailing Address - Phone:805-459-2250
Mailing Address - Fax:
Practice Address - Street 1:7246 REMMET AVE
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1531
Practice Address - Country:US
Practice Address - Phone:805-459-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62030207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D66581Medicare UPIN