Basic Information
| Provider Information | |||||||||
| NPI: | 1821068214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAXMAN | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1187 COAST VILLAGE RD | ||||||||
| Address2: | 492 | ||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931082737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055697316 | ||||||||
| FaxNumber: | 8055697317 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W PUEBLO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931054311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055697316 | ||||||||
| FaxNumber: | 8055697317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 08/29/2007 | ||||||||
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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 | G32872 | CA | Y | Other Service Providers | Specialist |
No ID Information.