Provider Demographics
NPI:1740286384
Name:KUETTEL, KEVIN D (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:KUETTEL
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 1:1211 W LA PALMA AVE
Mailing Address - Street 2:STE 306
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2811
Mailing Address - Country:US
Mailing Address - Phone:714-778-1300
Mailing Address - Fax:714-778-0303
Practice Address - Street 1:1211 W LA PALMA AVE
Practice Address - Street 2:STE 306
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2811
Practice Address - Country:US
Practice Address - Phone:714-778-1300
Practice Address - Fax:714-778-0303
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44004174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ82646ZMedicaid
CAZZZ82646ZMedicaid
CAW2945AMedicare PIN
CAF43374Medicare UPIN