Provider Demographics
NPI:1649267071
Name:ABJELINA, KENNETH T (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:T
Last Name:ABJELINA
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:PO BOX 2490
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-8490
Mailing Address - Country:US
Mailing Address - Phone:424-400-7748
Mailing Address - Fax:
Practice Address - Street 1:23700 CAMINO DEL SOL
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5017
Practice Address - Country:US
Practice Address - Phone:310-530-1151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA647892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A647890Medicaid
CA00A647890OtherBCBS
H48585Medicare UPIN
CAW17075Medicare ID - Type Unspecified