Basic Information
| Provider Information | |||||||||
| NPI: | 1568472389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2428 SANTA MONICA BLVD | ||||||||
| Address2: | SUITE LL | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103151000 | ||||||||
| FaxNumber: | 3108290348 | ||||||||
| Practice Location | |||||||||
| Address1: | 2428 SANTA MONICA BLVD | ||||||||
| Address2: | SUITE LL | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103151000 | ||||||||
| FaxNumber: | 3108290348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 03/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G35245 | CA | N | Other Service Providers | Specialist | 2085R0202X | G35245 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.