Healthcare Provider Details

I. General information

NPI: 1225370679
Provider Name (Legal Business Name): KEITH ANDREW KAGAHASTIAN EBILANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 W REDONDO BEACH BLVD
GARDENA CA
90247-3411
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 310-225-2825
  • Fax:
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA140101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: