Basic Information
| Provider Information | |||||||||
| NPI: | 1649267071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABJELINA | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2490 | ||||||||
| Address2: | |||||||||
| City: | PALOS VERDES PENINSULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902748490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4244007748 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23700 CAMINO DEL SOL | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905055017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105301151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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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 | 2084P0800X | A64789 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A647890 | 05 | CA | MEDICAID | 00A647890 | 01 | CA | BCBS | OTHER |