Provider Demographics
NPI:1124144266
Name:SI, KENAN (MD)
Entity type:Individual
Prefix:
First Name:KENAN
Middle Name:
Last Name:SI
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 1:331 J ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-2211
Mailing Address - Country:US
Mailing Address - Phone:916-553-0028
Mailing Address - Fax:916-553-0038
Practice Address - Street 1:331 J ST
Practice Address - Street 2:SUITE 150
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-2211
Practice Address - Country:US
Practice Address - Phone:916-553-0028
Practice Address - Fax:916-553-0038
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99168261QC1500X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health