Provider Demographics
NPI:1366415036
Name:EPSTEIN, KENNETH A (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:EPSTEIN
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 1:1338 W FOREST MEADOWS ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7218
Mailing Address - Country:US
Mailing Address - Phone:928-213-8631
Mailing Address - Fax:928-213-8632
Practice Address - Street 1:1338 W FOREST MEADOWS ST
Practice Address - Street 2:SUITE 140
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7218
Practice Address - Country:US
Practice Address - Phone:928-213-8631
Practice Address - Fax:928-213-8632
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19589207RA0201X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ296964Medicaid
E77524Medicare UPIN
AZ296964Medicaid
AZZ111164Medicare PIN
11WCHMN04Medicare ID - Type Unspecified