Provider Demographics
NPI:1184612327
Name:COUNTRYMAN, LOUIS KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:KENNETH
Last Name:COUNTRYMAN
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 1:375 HUNTINGTON DR
Mailing Address - Street 2:# D
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2357
Mailing Address - Country:US
Mailing Address - Phone:626-287-9611
Mailing Address - Fax:626-799-2904
Practice Address - Street 1:375 HUNTINGTON DR
Practice Address - Street 2:# D
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2357
Practice Address - Country:US
Practice Address - Phone:626-287-9611
Practice Address - Fax:626-799-2904
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG5963174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB58041Medicare UPIN