Provider Demographics
NPI:1902014780
Name:KINBACK, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:KINBACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7450
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-7450
Mailing Address - Country:US
Mailing Address - Phone:949-768-2988
Mailing Address - Fax:949-768-2980
Practice Address - Street 1:333 CORPORATE DR STE 260
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-2180
Practice Address - Country:US
Practice Address - Phone:949-768-2988
Practice Address - Fax:949-768-2980
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG774122084P0800X, 2084P0805X, 2084P0805X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77412CMedicare ID - Type Unspecified
CAF73861Medicare UPIN