Healthcare Provider Details

I. General information

NPI: 1538195672
Provider Name (Legal Business Name): KEVIN RICHARD COLWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 ALAMO ST
SIMI VALLEY CA
93063-2111
US

IV. Provider business mailing address

3900 ALAMO ST
SIMI VALLEY CA
93063-2111
US

V. Phone/Fax

Practice location:
  • Phone: 888-515-3500
  • Fax: 805-582-3088
Mailing address:
  • Phone: 888-515-3500
  • Fax: 805-582-3088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA69040
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA69040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: