Healthcare Provider Details

I. General information

NPI: 1043417447
Provider Name (Legal Business Name): CHARLES D KENYON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N LAKEVIEW AVE
ANAHEIM CA
92807-3028
US

IV. Provider business mailing address

17081 WESTPORT DR
HUNTINGTON BEACH CA
92649-4219
US

V. Phone/Fax

Practice location:
  • Phone: 714-279-5449
  • Fax:
Mailing address:
  • Phone: 714-846-4913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberG23234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: