Provider Demographics
NPI:1538195672
Name:COLWELL, KEVIN RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RICHARD
Last Name:COLWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3900 ALAMO ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2111
Mailing Address - Country:US
Mailing Address - Phone:888-515-3500
Mailing Address - Fax:805-582-3088
Practice Address - Street 1:3900 ALAMO ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2111
Practice Address - Country:US
Practice Address - Phone:888-515-3500
Practice Address - Fax:805-582-3088
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69040208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH39178Medicare UPIN