Basic Information
| Provider Information | |||||||||
| NPI: | 1790875276 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIWAN | ||||||||
| FirstName: | ELIAS | ||||||||
| MiddleName: | NICOLAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 29TH STREET | ||||||||
| Address2: | SUITE 680 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164533300 | ||||||||
| FaxNumber: | 9164533313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
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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 | 207R00000X | E-3479 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | E-3479 | AR | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RH0003X | C54469 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 150033001 | 05 | AR | MEDICAID |