Healthcare Provider Details

I. General information

NPI: 1003980822
Provider Name (Legal Business Name): KENNETH C WEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 BRISTOL ST SUITE 600
COSTA MESA CA
92626-3093
US

IV. Provider business mailing address

3080 BRISTOL ST SUITE 600
COSTA MESA CA
92626-3093
US

V. Phone/Fax

Practice location:
  • Phone: 714-445-0220
  • Fax: 714-445-0246
Mailing address:
  • Phone: 714-445-0220
  • Fax: 714-445-0246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number231432
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: