Healthcare Provider Details

I. General information

NPI: 1861460990
Provider Name (Legal Business Name): KENNETH D. LAXER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VAN NESS AVE
SAN FRANCISCO CA
94109-6978
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-7880
  • Fax: 415-369-1373
Mailing address:
  • Phone: 415-600-7880
  • Fax: 415-369-1373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG28500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: