Provider Demographics
NPI:1336242999
Name:TISHLER, KEVIN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:TISHLER
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 1:15082 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1301
Mailing Address - Country:US
Mailing Address - Phone:562-947-6600
Mailing Address - Fax:562-947-8907
Practice Address - Street 1:15082 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1301
Practice Address - Country:US
Practice Address - Phone:562-947-6600
Practice Address - Fax:562-947-8907
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73980208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G739800Medicaid