Healthcare Provider Details

I. General information

NPI: 1487761631
Provider Name (Legal Business Name): COLLEEN A KRAFT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 SAN JOAQUIN HILLS RD
NEWPORT BEACH CA
92660-6505
US

IV. Provider business mailing address

2075 SAN JOAQUIN HILLS RD
NEWPORT BEACH CA
92660-6505
US

V. Phone/Fax

Practice location:
  • Phone: 949-760-9222
  • Fax:
Mailing address:
  • Phone: 949-760-9222
  • Fax: 949-629-3509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG47936
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.123129
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: