Basic Information
| Provider Information | |||||||||
| NPI: | 1851646566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILLINGWORTH | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4140 W 190TH ST | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905045513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109671780 | ||||||||
| FaxNumber: | 8669914287 | ||||||||
| Practice Location | |||||||||
| Address1: | 8700 BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900481804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104239900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 125.061286 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | A147674 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.