Healthcare Provider Details

I. General information

NPI: 1184612327
Provider Name (Legal Business Name): LOUIS KENNETH COUNTRYMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 HUNTINGTON DR # D
SAN MARINO CA
91108-2357
US

IV. Provider business mailing address

375 HUNTINGTON DR # D
SAN MARINO CA
91108-2357
US

V. Phone/Fax

Practice location:
  • Phone: 626-287-9611
  • Fax: 626-799-2904
Mailing address:
  • Phone: 626-287-9611
  • Fax: 626-799-2904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG5963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: