Provider Demographics
NPI:1255379681
Name:KANGAH, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:KANGAH
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 1:3606 HIGHLAND AVE 108
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-2608
Mailing Address - Country:US
Mailing Address - Phone:909-864-1006
Mailing Address - Fax:909-864-1625
Practice Address - Street 1:3606 HIGHLAND AVE 108
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-2608
Practice Address - Country:US
Practice Address - Phone:909-864-1006
Practice Address - Fax:909-864-1625
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55122208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A551220Medicaid
CA00A551220Medicaid