Provider Demographics
NPI:1669577128
Name:PIERCE, KENNETH B (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:PIERCE
Suffix:
Gender:M
Credentials:DO
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 1341
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92674-1341
Mailing Address - Country:US
Mailing Address - Phone:808-652-6060
Mailing Address - Fax:888-323-0575
Practice Address - Street 1:305 CAZADOR LN APT C
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-6642
Practice Address - Country:US
Practice Address - Phone:808-652-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-754207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIE15889Medicare UPIN