Healthcare Provider Details

I. General information

NPI: 1205042470
Provider Name (Legal Business Name): SCOTT KAISER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST STE 150
SANTA MONICA CA
90404-2050
US

IV. Provider business mailing address

1301 20TH ST SUITE 230
SANTA MONICA CA
90404-2050
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7450
  • Fax: 310-582-7495
Mailing address:
  • Phone: 310-828-4411
  • Fax: 310-828-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number225913
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA120608
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number235987
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA120608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: