Provider Demographics
NPI:1396858429
Name:HILLIARD, GENERAL KEMP (MD MEDICAL DOCTOR)
Entity type:Individual
Prefix:DR
First Name:GENERAL
Middle Name:KEMP
Last Name:HILLIARD
Suffix:
Gender:M
Credentials:MD MEDICAL DOCTOR
Other - Prefix:
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Mailing Address - Street 1:13847 E 14TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2632
Mailing Address - Country:US
Mailing Address - Phone:510-352-5325
Mailing Address - Fax:510-351-7446
Practice Address - Street 1:13847 E 14TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2632
Practice Address - Country:US
Practice Address - Phone:510-352-5325
Practice Address - Fax:510-352-5325
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2010-11-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC32269207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0762736Medicaid
CAOOC322690Medicare ID - Type Unspecified
CA0762736Medicaid