Healthcare Provider Details

I. General information

NPI: 1053417212
Provider Name (Legal Business Name): PENN, KANAYA, DWELLE, MD'S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GARDEN RD STE 110
MONTEREY CA
93940-5334
US

IV. Provider business mailing address

1900 GARDEN RD SUITE 110
MONTEREY CA
93940-5373
US

V. Phone/Fax

Practice location:
  • Phone: 831-372-5841
  • Fax: 831-372-4820
Mailing address:
  • Phone: 831-372-5841
  • Fax: 831-372-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHIE L STARK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 831-372-5841