Healthcare Provider Details

I. General information

NPI: 1154313880
Provider Name (Legal Business Name): KENNETH S HEPPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 ETIWANDA AVE STE 110
TARZANA CA
91356-3642
US

IV. Provider business mailing address

5525 ETIWANDA AVE STE 110
TARZANA CA
91356-3642
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-4796
  • Fax: 844-406-5413
Mailing address:
  • Phone: 818-996-4796
  • Fax: 844-406-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG60798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: