Provider Demographics
NPI:1265433965
Name:TYE, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:TYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KUANG HUNG
Other - Middle Name:
Other - Last Name:TYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD,
Mailing Address - Street 1:1250 S SUNSET AVE
Mailing Address - Street 2:SUITE202
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3961
Mailing Address - Country:US
Mailing Address - Phone:626-960-6588
Mailing Address - Fax:626-338-0688
Practice Address - Street 1:1250 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3962
Practice Address - Country:US
Practice Address - Phone:626-960-6588
Practice Address - Fax:626-338-0688
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32035207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA32035OtherSTATE LICENSE NUMBER
CAW487Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ARA32035OtherSTATE LICENSE NUMBER