Provider Demographics
NPI:1154406718
Name:KIENLE, GEORGE S (DO)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:S
Last Name:KIENLE
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 1:1555 HIGUERA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2917
Mailing Address - Country:US
Mailing Address - Phone:805-543-4043
Mailing Address - Fax:805-543-4427
Practice Address - Street 1:1555 HIGUERA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2917
Practice Address - Country:US
Practice Address - Phone:805-543-4043
Practice Address - Fax:805-543-4427
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7588391OtherCIGNA HEALTH CARE PIN
CAW20A8454BMedicare PIN
7588391OtherCIGNA HEALTH CARE PIN
CAW20A8454DMedicare PIN
CAW20A8454CMedicare PIN