=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609296722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN P CARNEVALE JR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2014
-----------------------------------------------------
Last Update Date | 09/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1364 N WATERMAN AVE
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-361-3061
-----------------------------------------------------
Fax | 909-677-2113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 WESTERN AVE STE 204
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92411-1353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-474-9952
-----------------------------------------------------
Fax | 909-474-9951
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | A140393
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------