Basic Information
| Provider Information | |||||||||
| NPI: | 1306898721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910129 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921910129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585641400 | ||||||||
| FaxNumber: | 8585641500 | ||||||||
| Practice Location | |||||||||
| Address1: | 36320 INLAND VALLEY DR | ||||||||
| Address2: | STE 101 | ||||||||
| City: | WILDOMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925957512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516003811 | ||||||||
| FaxNumber: | 9516004493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G85088 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G850880 | 05 | CA | MEDICAID |