Provider Demographics
NPI:1356761571
Name:ORTIZ, KENNETH KALEOALOHA (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KALEOALOHA
Last Name:ORTIZ
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 1:4058 WILLOWS RD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-1668
Mailing Address - Country:US
Mailing Address - Phone:800-400-1189
Mailing Address - Fax:
Practice Address - Street 1:4058 WILLOWS RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1668
Practice Address - Country:US
Practice Address - Phone:800-400-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-27
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA156607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60747855OtherWA MD LICENSE
CAA1566607OtherCA MD LICENSE
ORMD181044OtherOR MD LICENSE