Provider Demographics
NPI:1356344022
Name:MCKENNAN, KEVIN X (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:X
Last Name:MCKENNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1111 EXPOSITION BLVD
Mailing Address - Street 2:BLDG 700
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4300
Mailing Address - Country:US
Mailing Address - Phone:916-736-3399
Mailing Address - Fax:916-233-4171
Practice Address - Street 1:1111 EXPOSITION BLVD BLDG 700
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4314
Practice Address - Country:US
Practice Address - Phone:916-736-3408
Practice Address - Fax:916-233-4171
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40176207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA040003543OtherRR MEDICARE PIN
CAA48124Medicare UPIN
CA00G401760Medicare PIN