Provider Demographics
NPI:1689605941
Name:KLEINMAN, KENNETH S (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:KLEINMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 ETIWANDA AVE STE 312
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-6126
Mailing Address - Country:US
Mailing Address - Phone:818-300-0081
Mailing Address - Fax:818-300-0081
Practice Address - Street 1:5525 ETIWANDA AVE STE 312
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-6126
Practice Address - Country:US
Practice Address - Phone:818-300-0081
Practice Address - Fax:818-300-0081
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50719174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
95-4372419OtherGROUP TAX ID
CA00G507190Medicaid
CAGR0079020Medicaid
CAWG50719CMedicare PIN
A51788Medicare UPIN
CAGR0079020Medicaid
WG50719BMedicare ID - Type UnspecifiedPPIN
110057040Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID