Provider Demographics
NPI:1053417212
Name:PENN, KANAYA, DWELLE, MD'S
Entity type:Organization
Organization Name:PENN, KANAYA, DWELLE, MD'S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-372-5841
Mailing Address - Street 1:1900 GARDEN RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5373
Mailing Address - Country:US
Mailing Address - Phone:831-372-5841
Mailing Address - Fax:831-372-4820
Practice Address - Street 1:1900 GARDEN RD STE 110
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5334
Practice Address - Country:US
Practice Address - Phone:831-372-5841
Practice Address - Fax:831-372-4820
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN, KANAYA, DWELLE, MD'S
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-15
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053417212Medicaid
CADA393AMedicare PIN