Healthcare Provider Details

I. General information

NPI: 1083826382
Provider Name (Legal Business Name): KENNETH ROY KAFKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 CARRILLO DRIVE SUITE 210
LOS ANGELES CA
90048-5400
US

IV. Provider business mailing address

955 CARRILLO DR STE 210
LOS ANGELES CA
90048-5400
US

V. Phone/Fax

Practice location:
  • Phone: 310-888-7778
  • Fax: 323-938-1028
Mailing address:
  • Phone: 310-888-7778
  • Fax: 323-938-1028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG86040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: