Provider Demographics
NPI:1881693174
Name:OPENSHAW, KURT (MD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:OPENSHAW
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 1:1140 W LA VETA AVE STE 850
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4218
Mailing Address - Country:US
Mailing Address - Phone:714-560-4450
Mailing Address - Fax:714-560-4455
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:STE. 850
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4225
Practice Address - Country:US
Practice Address - Phone:714-560-4450
Practice Address - Fax:714-560-4455
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG639242085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G639240Medicaid
00G639240 M46OtherCALOPTIMA
O00109845OtherRAILROAD MEDICARE
053304CF32713OtherTRAILBLAZER
00G639240OtherBLUE SHIELD OF CA
053304CF32713OtherTRAILBLAZER
O00109845OtherRAILROAD MEDICARE