Basic Information
| Provider Information | |||||||||
| NPI: | 1982097549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | 72-235 CHS | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900951749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108256643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900952909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108256643 | ||||||||
| FaxNumber: | 3102670369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2015 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.