Healthcare Provider Details

I. General information

NPI: 1366415036
Provider Name (Legal Business Name): KENNETH A EPSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 W FOREST MEADOWS ST SUITE 140
FLAGSTAFF AZ
86001-7218
US

IV. Provider business mailing address

1338 W FOREST MEADOWS ST SUITE 140
FLAGSTAFF AZ
86001-7218
US

V. Phone/Fax

Practice location:
  • Phone: 928-213-8631
  • Fax: 928-213-8632
Mailing address:
  • Phone: 928-213-8631
  • Fax: 928-213-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number19589
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number19589
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: