Healthcare Provider Details

I. General information

NPI: 1235437575
Provider Name (Legal Business Name): KENNETH EARL FOLLMAR III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 10/15/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1294 W 6TH ST STE 102
SAN PEDRO CA
90731-2997
US

IV. Provider business mailing address

1294 W 6TH ST STE 102
SAN PEDRO CA
90731-2997
US

V. Phone/Fax

Practice location:
  • Phone: 310-944-1108
  • Fax:
Mailing address:
  • Phone: 310-944-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA103360
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: