Basic Information
| Provider Information | |||||||||
| NPI: | 1538273008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLINA | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY # MC5064 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665841 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665841 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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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 | 208000000X | J3298 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | J3298 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | 153469 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110625102 | 01 | TX | FIRSTCARE PIN | OTHER | 125007806 | 05 | TX | MEDICAID | 140442852 | 05 | TX | MEDICAID | 1218867 | 01 | TX | FIRSTHEALTH PIN | OTHER | 124106 | 01 | TX | SUPERIOR PIN | OTHER | 88705G | 01 | TX | BCBSTX IND PIN | OTHER | 00U87Z | 01 | TX | BCBSTX GRP PIN | OTHER | 1750369203 | 01 | GRP NPI NUMBER | OTHER | 2352398 | 01 | TX | UHC PIN | OTHER | 4536787 | 01 | TX | AETNA PIN | OTHER | 7097804 | 01 | TX | CIGNA PIN | OTHER | 137345810 | 05 | TX | MEDICAID | 10011558 | 01 | TX | AMERIGROUP PIN | OTHER | 125007805 | 05 | TX | MEDICAID |