Healthcare Provider Details

I. General information

NPI: 1437309275
Provider Name (Legal Business Name): GEOFFREY KU KENYOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MAIN ST PEDIATRICS
SANTA ANA CA
92701-3576
US

IV. Provider business mailing address

18081 BEACH BLVD
HUNTINGTON BEACH CA
92648-1304
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7011
  • Fax:
Mailing address:
  • Phone: 714-841-7330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106855
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: