Provider Demographics
NPI:1013984020
Name:WIN, KENNY CHAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:CHAN
Last Name:WIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHAN
Other - Middle Name:
Other - Last Name:WIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3102 E. HIGHLAND AVENUE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369
Mailing Address - Country:US
Mailing Address - Phone:909-425-7679
Mailing Address - Fax:909-425-6635
Practice Address - Street 1:3102 E. HIGHLAND AVENUE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369
Practice Address - Country:US
Practice Address - Phone:909-425-7679
Practice Address - Fax:909-425-6635
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8575128Medicaid
CA00A544981Medicare ID - Type Unspecified
CA8575128Medicaid