Provider Demographics
NPI:1811904626
Name:WAITS, KEVIN A (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:WAITS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 SISTER MARY COLUMBA DR
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-4356
Mailing Address - Country:US
Mailing Address - Phone:530-528-8697
Mailing Address - Fax:530-528-8426
Practice Address - Street 1:2430 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4356
Practice Address - Country:US
Practice Address - Phone:530-528-8697
Practice Address - Fax:530-528-8426
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7514207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A75140Medicare ID - Type Unspecified
CAF68492Medicare UPIN