Provider Demographics
NPI:1548280423
Name:LYNN, KENNETH ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:LYNN
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 1:24411 HEALTH CENTER DR STE 690
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3687
Mailing Address - Country:US
Mailing Address - Phone:949-452-7034
Mailing Address - Fax:949-458-8810
Practice Address - Street 1:24411 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3651
Practice Address - Country:US
Practice Address - Phone:949-452-7034
Practice Address - Fax:949-458-8810
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59849174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93546Medicare UPIN