Healthcare Provider Details

I. General information

NPI: 1831886647
Provider Name (Legal Business Name): MR. KEVIN MICHAEL PARHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 HOTEL CIR N STE 101&314
SAN DIEGO CA
92108-2807
US

IV. Provider business mailing address

1660 HOTEL CIR N STE 101&314
SAN DIEGO CA
92108-2807
US

V. Phone/Fax

Practice location:
  • Phone: 619-961-2120
  • Fax:
Mailing address:
  • Phone: 619-961-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberMPSS-TRQZHP
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-TRQZHP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: