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NPI Code Detail

MEDICARE: DR. LOUIS KENNETH COUNTRYMAN M.D.

MEDICARE: DR. LOUIS KENNETH COUNTRYMAN M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialistG5963CA

General Provider Information

NPI Number : 1184612327
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. LOUIS KENNETH COUNTRYMAN M.D.
Provider Business Mailing Address
First Line : 375 HUNTINGTON DR
Second Line : # D
City : SAN MARINO
State : CA
Zip : 91108-2357
Country : US
Telephone Number : 626-287-9611
Fax Number : 626-799-2904
Provider Business Practice Location Address
First Line : 375 HUNTINGTON DR
Second Line : # D
City : SAN MARINO
State : CA
Zip : 91108-2357
Country : US
Telephone Number : 626-287-9611
Fax Number : 626-799-2904
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/12/2005
Last Update Date : 07/08/2007

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