MEDICARE: PATRICIA MARIE KETTLEHAKE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A68312	CA
2	208000000X	Pediatrics Physician	A68312	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831109982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA MARIE KETTLEHAKE MD

Provider Business Mailing Address
First Line	:	230 PROSPECT PL
Second Line	:	STE 220
City	:	CORONADO
State	:	CA
Zip	:	92118-1978
Country	:	US
Telephone Number	:	619-435-2670
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 PROSPECT PL
Second Line	:	STE 220
City	:	CORONADO
State	:	CA
Zip	:	92118-1978
Country	:	US
Telephone Number	:	619-435-2670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	10/19/2017

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