Provider Demographics
NPI:1801118716
Name:KENITH K PARESA, MD A PROFESSIONAL CORP
Entity type:Organization
Organization Name:KENITH K PARESA, MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENITH
Authorized Official - Middle Name:K
Authorized Official - Last Name:PARESA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-659-9566
Mailing Address - Street 1:15332 ANTIOCH ST # 530
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3628
Mailing Address - Country:US
Mailing Address - Phone:310-874-8430
Mailing Address - Fax:714-917-4620
Practice Address - Street 1:1964 WESTWOOD BLVD STE 435
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-856-9488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA662332081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACT521AMedicare PIN