Provider Demographics
NPI:1134388879
Name:DE LOS REYES, KENNETH MARCEL (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARCEL
Last Name:DE LOS REYES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11234 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1716
Mailing Address - Country:US
Mailing Address - Phone:909-558-4419
Mailing Address - Fax:909-558-4825
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1716
Practice Address - Country:US
Practice Address - Phone:909-558-4419
Practice Address - Fax:909-558-4825
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC131686207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1134388879Medicaid