Provider Demographics
NPI:1205932407
Name:PHILLIPS, KENNETH K JR (DPM)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:K
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:DPM
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Mailing Address - Street 1:74090 EL PASO
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260
Mailing Address - Country:US
Mailing Address - Phone:760-773-3338
Mailing Address - Fax:760-779-8242
Practice Address - Street 1:74090 EL PASO
Practice Address - Street 2:SUITE 100
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-773-3338
Practice Address - Fax:760-779-8242
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2010-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAE3419213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T11684Medicare UPIN
000E34190Medicare ID - Type Unspecified