Healthcare Provider Details

I. General information

NPI: 1093804304
Provider Name (Legal Business Name): KENNETH E NYMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 ETIWANDA AVE SUITE 222
TARZANA CA
91356-3647
US

IV. Provider business mailing address

18375 VENTURA BLVD SUITE 626
TARZANA CA
91356-4218
US

V. Phone/Fax

Practice location:
  • Phone: 818-344-1001
  • Fax: 818-344-4547
Mailing address:
  • Phone: 818-908-8048
  • Fax: 818-908-8072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG27055
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberG27055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: